LECTURES ON * CLINICAL MEDICINE. Vol. I. LECTURES ON Clinical Medicine BY A. TROUSSEAU, LATE PROFESSOR OF CLINICAL MEDICINE IN THE FACULTY OF MEDICINE, PARIS; PHYSICIAN TO THE h6tel-dieu; member of the imperial academy of medicine; commander of the LEGION OF HONOR; GRAND OFFICER OF THE ORDER OF THE LION AND THE SUN OF PERSIA; EX REPRESENTATIVE OF THE PEOPLE IN THE NATIONAL ASSEMBLYJ ETC., ETC. TRANSLATED FROM THE THIRD REVISED AND ENLARGED EDITION, BY Sir JOHN ROSE CORMACK, M.D., F.R.S.E., FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH ; AND FORMERLY LECTURER ON FORENSIC MEDICINE IN THE MEDICAL SCHOOL OF EDINBURGH; ETC., ETC. AKD r P. VICTOR BAZIRE, M.D., ASSISTANT PHYSICIAN TO THE NATIONAL HOSPITAL FOR THE PARALYZED; ETC., ETC. Complete in Two Volumes. Vol. I. PHILADELPHIXJ LINDSAY & BLAKISTON. 1 8 73. PHILADELPHIA: PRINTED BY SHERMAN & CO. PUBLISHERS' NOTICE. In the London edition of this work, published in five volumes, Volume I contains twenty-three selected Lectures, viz., 39 to 51, and 53 to 61, inclusive, and 66, in all twenty-three, which were translated by the late Dr. Bazire, and to which he added notes. All the other Lectures in the four remaining volumes were translated by Dr. John Rose Cormack for the Sydenham Society, without notes. In reprinting this edition in two volumes, the twenty-three Lectures above referred to have been placed in their regular order of sequence, as delivered by the late Professor Trousseau, at the Hotel-Dieu, Paris (omitting Dr. Bazire's notes), that easy reference can be had to the Third and last French edition, from which this translation is made. Philadelphia, September, 1873. ADVERTISEMENT. In this third edition, the work has undergone important modifica- tions. For the accomplishment of this editorial labor, M. Trousseau selected his former chef de clinique, M. Michel Peter, now Professor Agrege of the Faculty of Medicine, and Physician to the Hospitals of Paris. The first and second volumes were revised and corrected in accordance with the suggestions and under the control of M. Trous- seau. M. Peter modified the third volume in conformity with the sug- gestions of his master, who had ceased to live when that volume was being prepared ; he had, however, left instructions regarding it, which were scrupulously followed. As the interpreter of his venerated mas- ter, M. Peter has striven to be equal to his task, and to represent faith- fully the latest sayings of that profound and eloquent man whose voice is now forever silenced. Among the most extensive additions may be mentioned, researches regarding temperature in diseases, particularly in eruptive fevers and dothinenteritis; granular and waxy degeneration of muscles; leucocy- tosis in typhoid fever; the spinal and cerebro-spinal type of typhoid fever; the application of the sphygmograph in diseases of the heart and in epilepsy; the laryngoscope in lesions of the lungs; and the ophthalmoscope in cerebral affections. Besides additions, of which only the most important have been men- tioned, a great number of lectures have been retouched, and some have even been rewritten. For example, the lecture on aphonia and cauter- ization of the larynx has been entirely recast, in consequence of the new views derived from the use of the laryngoscope; the lecture on hydrophobia has been recast; also that on alcoholism, in which have been incorporated the careful researches with which contemporary XVI ADVERTISEMENT. science has enriched this subject. Next to the lectures now enumerated may be specified as having been most largely modified, those on pelvic hsematocele, puerperal purulent infection, and phlegmasia alba dolens. Cases have been added whenever they imparted greater perspicuity, or contributed new views. In the advertisement to the second edition, M. Trousseau recorded that MM. Leon Blondeau, Dumontpallier, and Peter, had "all three done more than merely edit his work; they had assisted him in his researches, and had often yielded to him the honor of very interesting inquiries, thereby making to a certain extent, a sacrifice on his account." It would have been unjust not to have here reproduced this grateful testimony of a deceased master. Paris, 4th November, 1867. CONTENTS OF FIRST VOLUME. PAGE Publishers' Notice,xiii Advertisement, xv Introduction: What is Clinical Medicine?33-61 LECTURE I. SMALL-POX. Distinct Small-Pox.-Constipation.-Convulsions.-Rachialgia.-Paraplegia of Small-pox.-Duration of the Period of Invasion.-Eruption with Reference to its Position on Face, Trunk, and Limbs.-Orchitis of Small-pox.-Desicca- tion, . 63-73 Confluent Small-Pox.-Diarrhoea chiefly in Children at the Commencement of the Illness.-Salivation.-Swelling of the Face.-Swelling of the Hands, and Nervous Complications.-Boils.-Abscesses.-Purulent Infection.-Albuminu- ria.-Anasarca.-Treatment, 73-90 . A LECTURE II. VARIOLOUS INOCULATION. Advantages of Inoculation.-Experiments on Clavelization.-Dangers of Inocula- tion and Means of diminishing them.-Methods of Inoculating.-The Mother- Pock and its Satellites.-General Symptoms,90-96 LECTURE III. COW-POX. Grease of Horses.-Cow-pox in the Cow.-Cow-pox in the Human Subject.-Cow- pox and Horse-pox are Analogous to, but Not Identical with Small-pox- Practical Importance of this Distinction.-Regeneration of Cow-pox, . 96-111 XVIII CONTENTS OF FIRST VOLUME. Transmission of Cow-pox from Man to Man.-Circumstances Favorable to Success- ful Vaccination.-The Lymph ought to be taken between the Fifth and Seventh Days.-Selection of Subjects from whom the Lymph ought to be taken.-Health of Persons who are to be Vaccinated.-Transmission of Syphilis in Vaccina- tion.-Vaccinal Eruptions.-Modified Cow-pox.-Regeneration of Lymph.- Revaccination.-Vaccination at the Bar of Public Opinion, . . 111-133 LECTURE IV. CHICKEN-POX. Chicken-pox or Varicella essentially different from Modified Small-pox.-Unlike Small-pox, it does not protect from Variolous Contagion.-Small-pox does not protect from Chicken-pox.-Course and Characteristics of the Eruption, 133-136 LECTURE V. SCARLATINA. Variety in the Characters of Epidemics.-Contagion.-Incubation.-Complica- tions at the Beginning of an Attack.-Characters of the Eruption.-Desqua- mation, 136-145 Cerebral and Nervous Complications.-Sore Throat complicated with Diphtheria.- Buboes.-Rheumatism,146-151 Complications occurring during the Decline of the Disease.-Anasarca.-Hsematu- ria.-Albuminuria.-Convulsions.-(Edema of the Glottis.-Pleurisy.-Pericar- ditis.-Endocarditis.-Rheumatism.-Scarlatina without Eruption.-Anasarca without Eruption.-Treatment,151-170 LECTURE VI. measles; and in particular its unfavorable symptoms and COMPLICATIONS. Normal Measles.-Period of Invasion is longer than in any other Eruptive Fever.- Complications of the Period of Invasion.-Convulsions at the Beginning of the Attack.-False Croup-Suffocative Catarrh.-Epistaxis.-Otitis.-Diarrhoea.- Complications of the Eruptive Stage, and of the Last Stage, . . 170-185 LECTURE VII. RUBEOLA. Very Different Disease from Measles.-Stands in the same Relation to Measles as Chicken-pox to Small-pox.-Does not produce Catarrh of the Mucous Mem- brane.-No Serious Sequelae.-May attack the same person more than once, and does not confer Exemption from Measles,186-187 CONTENTS OF FIRST VOLUME. XIX LECTURE VIII. ERYTHEMA NODOSUM. A Specific and Separate Disease.-Successive Eruptions.-Articular Pains.- General Symptoms.-A Possible Manifestation of the Rheumatic Diathesis, 187-190 LECTURE IX. ERYTHEMA PAPULATUM. Differs from Erythema Nodosum in the Form of the Eruption, and in the Severity of the Symptoms.-Rheumatic Character, . , . 191-195 LECTURE X. erysipelas; and in particular erysipelas of the face. Pathology of Erysipelas.-Almost always an exciting Cause independent of Indi- vidual Predisposition and General Cause.-May Supervene in the Course of Epidemics.-Severity increased by Traumatic Influence.-General Symptoms dependent on Inflammation of Wound and Lymphatic Vessels.-Delirium has not the Signification attributed to it in Erysipelas.-Erysipelas sometimes Contagious.-When not a Complication of another Disease is a Mild Affection which subsides spontaneously.-Treatment ought to be Expectant, . 195-204 ERYSIPELAS OF NEW-BORN INFANTS. Affection often Puerperal.-Differs Essentially from Ordinary Erysipelas.-Gener- ally Fatal, 205-210 LECTURE XI. MUMPS. A Specific and Contagious Disease.-Metastases.-Complications, . 210-214 LECTURE XII. URTICARIA. A Distinct Nosological Species.-Sudoral Nettlerash \l'eruption ortiee sudorale] is no more Urticaria than Morbilliform and Scarlatiniform Sudoral Eruptions are Measles and Scarlatina.-General Precursory Symptoms.-Exciting Causes,215-218 XX CONTENTS OF FIRST VOLUME. LECTURE XIII. ZONA OR HERPES ZOSTER. Characteristics.-Accompanying Pains.-Inveterate Consecutive Neuralgic Affec- tions, 218-223 LECTURE XIV. SUDORAL EXANTHEMATA. Multiplicity of Forms.-Cutaneous and Mucous Exanthemata.-Physiological Causes.-Antagonism of the Secretions of the Skin and the Secretions of the Intestinal, Respiratory, and Urinary Mucous Membranes. - Exanthemata produced by Medicinal Agents -Sudoral Exanthemata becoming Purulent in Lying-in Women and Others.-Analogies between Sudoral Exanthemata and Exanthemata produced by a Virus or Dependent on Diathesis, . . 224-233 LECTURE XV. DOTHINENTERIA, OR TYPHOID FEVER. Specific Lesion.-Furuncular Eruption of the Intestine.-Intestinal Perforation.- Peritonitis without Perforation, 234-243 Intestinal Hemorrhage.-Hemorrhagic Putrid Fever, .... 243-248 Granular and Waxy Degeneration of the Striated Muscles in Typhoid Fever.- Nature and Consequences of this Degeneration.-Special Course of the Rise and Fall of Temperature in Typhoid Fever : this is characteristic.-Parallelism between the Course of Temperature and the Evolution of the Intestinal Le- sions, 248-255 Rosy Lenticular Spots.-Successive Eruptions.-Miliary Eruption.-Blue Spots, 255-258 Intestinal Dothinenteric Catarrh.-Its Specific Character.-Predominance of Intes- tinal and Pulmonary Catarrhal Affections constitutes the Forms of the Disease called " Abdominal " and " Thoracic," 258-260 Forms of Dothinenteria, viz., the Mucous, Bilious, Inflammatory, Adynamic, Ataxic, Spinal, Cerebro-Spinal, and Malignant, .... 261-267 Parotitis and Deafness as Prognostic Signs of Dothinenteria, . . . 267-268 Dothinenteria may at first simulate Intermittent Fever; and Marsh [Intermittent] Fever may likewise at the beginning of the attack simulate Dothinenteria, 268-272 Contagion.-Conditions under which Dothinenteria occurs, . . . 272-276 Treatment of Dothinenteria.-Regimen of the Patients, .... 276-282 Affections which occur during Convalescence.-Gastric Disturbance.-Vomiting. -Diarrhoea.-Nervous Symptoms.-Vertigo.-Delirium.-Impaired Mental Power.-Paralysis.-Dropsical Effusions,, . 282-288 CONTENTS OF FIRST VOLUME. XXI Local Complications which Supervene during, and at the Decline of Dothinenteria.-Softening of the Cornea, Affections of the Larynx, Necrosis of the Cartilages of the Nose.-(Edema of the Glottis supervening during Dothinenteria, and necessitating Tracheotomy.-Sloughs.-Erysipelas.-Col- liquative Suppurations.-Paraplegia consecutive to Infiltration of Pus into the Spinal Canal producing Inflammation and Suppuration of the Spinal Marrow. -Spontaneous Gangrene of the Limbs, 288-305 LECTURE XVI. TYPHUS. An Infectious Disease like Dothinenteria.-Differs from Dothinenteria in the Ab- sence of Intestinal Lesions.-The two Fevers are distinguished from each other by the Aggregate of the Symptoms, and their Thermal Variations, . 305-315 * LECTURE XVII. MEMBRANOUS SORE THROAT, AND IN PARTICULAR HERPES OF THE PHARYNX. [COMMON MEMBRANOUS SORE THROAT.] Many Different Kinds of Membranous Sore Throat.-Common Membranous Sore Throat often originates in Herpes of the Pharynx.-Often difficult, especially during an epidemic, to form a good Differential Diagnosis between it and Diphtheritic Sore Throat.-In these Doubtful Cases we must act as if the malady were of a bad character.-Recovery from Common Membranous Sore Throat is Spontaneous,315-323 LECTURE XVIII. GANGRENOUS SORE THROAT. Gangrenous Sore Throat from Excess of Inflammation.-Gangrenous Sore Throat Supervening as a Complication of severe Diseases, such as Dysentery, Typhoid Fever, &c.-Gangrenous Sore Throat as a Complication of Scarlatinous and Diphtheritic Sore Throat.-Primary Gangrenous Sore Throat, . . 323-330 LECTURE XIX. INFLAMMATORY SORE THROAT. Recovery is Spontaneous.-Distinct from Rheumatic Sore Throat.-Distinct also from the Sore Throat caused by the Secretion from the Tonsils, . 330-335 XXII CONTENTS OF FIRST VOLUME. LECTURE XX. DIPHTHERIA. Diphtheritic Sore Throat and Croup. [Pharyngeal and Laryngeal Diphtheria.]-Occurs in all Climates and all Seasons.-Chiefly attacks Chil- dren.-Manner in which it is Propagated.-Glandular Swellings.-The Color of the False Membranes : their Smell simulating that of Gangrene.-Its Prop- agation to the Larynx.-Croup.-Intermittence of Symptoms.-Generally proves Fatal when its Progress is not Stopped, 335-352 Malignant Diphtheria.-A much more Terrible Form of the Disease.-The Local Affection is nothing compared to the Constitutional Symptoms.-It Kills, not like Croup by Asphyxiating the Patients by Suffocative Paroxysms, but it Kills by General Poisoning after the manner of Septic Diseases.-Glandular Engorgement considerable.-Erysipelatous Redness.-Membranous Coryza and Nasal Diphtheria.-Diphtheritic Ophthalmia.-Epistaxis.-Hemorrhages of every kind.-Anaemia, 352-361 ♦ Diversity oe Localization in Diphtheria.-Palpebral Diphtheria.-Cutaneous, Vulvar, Vaginal, Anal, and Preputial Diphtheria, .... 361-372 Diphtheria oe the.Mouth.-Of all the Manifestations of Diphtheria, it has the greatest Tendency to remain confined to its own Locality.-May be Propagated to the Pharynx and Larynx, and produce Croup.-May lead to Gangrene.- May be a Manifestation of Malignant Diphtheria.-Exceedingly Contagious.- Epidemic, . 373-376 Nature oe Diphtheria:. Contagion: Alteration of the Blood: Albu- minuria, 376-382 Paralysis in Diphtheria.-Not a new disease.-The Mild Form.-Symptoms.- Paralysis of the Veil of the Palate, of the Senses, Limbs, and of the Muscles of Organic Life.-Death by Suffocation, by Strangling.-The Aggravated Form. -Ataxo-adynamic Symptoms.-The Gravity of the Paralysis bears neither any Relation to the Intensity or Duration of the1 Pseudo-membranous Affection, nor to the Albuminuria. This kind of Paralysis is the Result of Poisoning.- Treatment, 382-402 Treatment of Diphtheria and Croup.-The Antiphlogistic Treatment ought to be absolutely rejected.-Alterative Treatment: Mercurials useful as Topical Agents : their inconveniences : Alkalies, particularly Bicarbonate of Soda, of very doubtful benefit.-Chlorate of Potash useful in cases of average severity. -Emetic Treatment: its inconveniences greater than its advantages.-Serious Consequences produced by Blisters.-Topical Method of Treatment by Astrin- gents and Caustics is best treatment of Diphtheritic Affections.-Catheterism of the Larynx.-Indispensable Necessity of sustaining the Vital Powers of the Patients by Food and Tonic Medicines, 402-418 Tracheotomy.-Its Utility and Necessity.-Mode of Operating.-The Dilator.- Operation ought to be very slowly Performed: Dangers of rapid performance. CONTENTS OF FIRST VOLUME. XXIII -Dressing.-Cauterization of the Wound.-The Neckcloth.-General Treat- ment.-The chances of Success are the greater, the less energetic the anterior treatment has been.-Alimentation of the Patients.-Removal of the Canula.- Ififected Canulae.-A Condition Favorable to Success is to Operate as soon as possible.-Unfavorable Conditions.-Death is certain in Malignant Diphtheria: Death is almost certain in Children under two years, . . . 419-434 LECTURE XXI. THRUSH. Synonyms.-Micrographers regard it as Mycelium.-Arises from Modification of the Secretion produced by Inflammation of the Mouth.-In Adults is met with in advanced stage of nearly all Chronic Diseases.-Accompanying Intestinal Derangement.-In Children, supervenes also in Diseases, which, regard being had to the Age of the Subject, maybe considered Chronic.-Indicates, irrespec- tive of the cause, a general state of Inanition.-When purely local is not a seri- ous affection.-Mixed Thrush.-The Mouldy Eruption of Thrush may become developed on any mucous membrane covered with Epithelium, and having the Secretion altered.-The Different Erythematous Affections which accompany it depend upon a general state of the System.-Treatment: The Local Lesion is easily destroyed.-Necessary to continue the Use of Topical Agents for some days after the disappearance of Thrush, to modify the inflamed state of the Mucous Membrane.-The same treatment applicable to the Cutaneous Lesions.-When Thrush depends on a General Condition of the System, the Treatment must be directed to the removal of the Causes of that Con- dition, 434-442 LECTURE XXII. SPECIFIC ELEMENT IN DISEASE. The Specific Element is Dominant throughout the whole of Medicine.-Dichotomic Doctrines of Brown and Broussais.-Diseases have Certain Characters in Com- mon; and also Individual or Specific Characters.-Specific Causes.-Specific Symptoms.-Knowledge of Specific Character applied to Diagnosis, Prognosis, and Treatment, 442-457 LECTURE XXIII. CONTAGION. Definition.-Parasitical Diseases are not included.-Spontaneous Development of Morbid Germs.-Infection.-Infectious Diseases may become Contagious.- Dormant State of Germs.-Difference between Infection and Contagion.- Morbific Matter.-Conditions of Contagion: Inherent in Individuals and in Germs.-Immunity, Temporary and Absolute.-Conditions as to Age, and Previous Contamination.-Acclimation and Habit.-Apparent Immunity.- Modes of Transmission.-Contact.-Direct Inoculation.-Inhalation, 457-479 XXIV CONTENTS OF FIRST VOLUME. LECTURE XXIV. OZJENA. A very Common Affection.-Must not be confounded with Foetor of the Mouth or Throat.-Fetor of Ozsena is altogether Peculiar.-Sometimes Dependent on Alteration of the Secretions.-Fetor of Inflammatory Secretions in some per- sons.-Constitutional Ozsena.-Symptoms.-Syphilitic Ozsena very frequent.- Ulceration of the Mucous Membrane : Necrosis.-Diseases of the Maxillary Sinus.-Topical Treatment is the most usual.-Constitutional Treatment is very useful in Syphilitic Ozsena: also of considerable benefit in Herpetic and Scrof- ulous Ozaena.-Powder for snuffing up the Nose.-Injections.-Treatment must be very patient and very varied, 480-488 LECTURE XXV. STRIDULOUS LARYNGITIS, OR FALSE CROUP. Long confounded with Pseudo-membranous Croup.-Differs essentially from that disease in its Nature, Manner of Invasion, Progress, and Complications.- Croupy [Croupale] Cough presents characters very different from those of True Croup.-False Croup is not a dangerous disease; but still, in some very rare cases, it causes death.-The Prognosis is serious when the laryngeal affection is the forerunner of peripneumonic catarrh.-In the majority of cases, the Treat- ment ought to be Expectant, 488-495 LECTURE XXVI. (EDEMA OF THE LARYNX. (Edema of the Larynx is Not in itself a Disease : it is a Complication of Diseases of the Larynx.-Improperly named (Edema of the Glottis.-Sometimes, but not often, independent of Inflammation.-Predisposing Causes.-Exciting Causes. -Frequently supervenes in Chronic Laryngitis.-Common Termination of what is called Laryngeal Phthisis.-Treatment: Topical Medication is import- ant.-Often necessary to resort to Tracheotomy, .... 495-509 LECTURE XXVII. APHONIA: CAUTERIZATION OF THE LARYNX. Different Causes of Aphonia.-From Lesion, or without Lesion of the Larynx.- Nervous Aphonia.-Good Effects resulting from Cauterization, and sometimes even from the mere Introduction of the Laryngoscope, . . . 509-515 CONTENTS OF FIRST VOLUME. XXV LECTURE XXVIII. DILATATION OF THE BRONCHI AND BRONCHORRHCEA. Extreme Difficulty of Diagnosis.-Dilatation of the Bronchi may be mistaken for Pulmonary Phthisis-or for Pleurisy with Perforation of the Lung.-Dif- ferential Diagnosis.-Important Signification of Abundant and Fetid Expecto- ration.-Causes of the Fetor.-Dilatation of the Bronchi, unless it be to a very great degree, is not a Serious Affection.-Treatment of Bronchorrhoea, or Pul- monary Blenorrhagia.-Balsams.-Arsenical Inhalation, . . . 516-530 LECTURE XXIX. HEMOPTYSIS. Haemoptysis.-Supplementary Haemoptysis.-The Differential Diagnosis between the Haemoptysis symptomatic of Pulmonary Phthisis, and the Haemoptysis of Hemorrhagic Pneumonia, is by no means so easy as some physicians allege, 530-541 LECTURE XXX. PULMONARY PHTHISIS. Rapid Phthisis, or Galloping Consumption.-Rapid Phthisis is simply Ordi- nary Phthisis accomplishing its course in a very Short Period of Time.-Acute Phthisis is a Distinct Morbid Species, of which there are Two Forms, the Catar- rhal and the Typhoid, 541-547 Pulmonary Tuberculization, and Chronic Peripneumonic Catarrh in Children, 547-551 LECTURE XXXI. GANGRENE OF THE LUNG. Difficulties of Diagnosis.-Several Species of Gangrene of the Lung: One of them, the Species here more particularly considered, is Curable, . . . 551-556 LECTURE XXXII. PLEURISY: PARACENTESIS OF THE CHEST. Pleurisy.-Ordinary Signs.-Skoda's Bruit.-Interpretation of the Rubbing Sound.-Crepitant Rales of Pleurisy.-Persistence of Blowing Sound in Cases of Excessive Effusion.-Blowing Sound, and Amphoric Voice, are Signs of Pleurisy.-Mistakes in Diagnosis may sometimes occur.-Intercostal Fluctua- tion, . 556-565 VOL. I.-2 XXVI CONTENTS OF FIRST VOLUME. Paracentesis of the Chest.-Cases.-Historical Sketch of the Operation for Effusion into the Cavity of the Pleura, 565-580 Circumstances which render Paracentesis of the Chest necessary.-Pleurisy may be Fatal.-Profuse Effusion may cause Sudden Death.-It may occasion Death by Asphyxia.-On the other hand, Paracentesis may accomplish an Immediate Cure: when this takes place, the Temperature of the Body at once becomes normal.-The Continuance of the Effusion in the Chest may occasion Hectic Fever.-The Effusion may become Purulent.-Traumatic Pleurisy.-Pleurisy may occasion development of the Tubercular Diathesis.-Latent Pleurisy is a frequent manifestation of this Diathesis, whether the Effusion remain Serous, or become Purulent, as usually occurs.-Paracentesis is also useful when there exists Hydro-pneumothorax.-Cancerous Pleurisy, .... 580-611 The Quantity of the Effusion regulates the time at which Paracentesis is indicated. -The General Symptoms and Oppression of Breathing are Fallacious Indica- tions.-The only Trustworthy Signs are those furnished by Auscultation and Percussion.-The Manner of Operating.-Certain Phenomena which supervene during the Flow of the Fluid.-Coughing Fits.-Flow of Blood from the Wound. -The Serosity jellies in cooling, and sometimes assumes a rosy color.-Circum- scribed Pleurisies.-Objections to Paracentesis.-Paracentesis in Empyema.- Injections of Iodine ; and the Permanent Canula, .... 612-631 LECTURE XXXIII. TRAUMATIC EFFUSION OF BLOOD INTO THE PLEURA: PARACENTESIS OF THE CHEST. Effusion of Blood into the Cavity of the Pleura mechanically arrests Traumatic Hemorrhage.-In such cases, Paracentesis is not only useless, but may even prove injurious.-The Blood coagulates immediately.-It scarcely irritates the Pleura.-Reabsorption takes place very rapidly, .... 631-638 LECTURE XXXIV. HYDATIDS OF THE LUNG. Hydatids of the Lung though rare are not so rare as Hydatids of the Pleura.-Diag- nosis is exceedingly difficult.-Resemblance to Pulmonary Phthisis.-Possi- bility of Cure by Spontaneous Evacuation by the Bronchial Tubes.-Reserve required both in respect of the Prognosis and Treatment, . . . 638-649 LECTURE XXXV. PULMONARY ABSCESSES AND PERIPNEUMONIC VOMIC2E. Rare Affections, if we exclude from the category Tubercular Vomicae and Metas- tatic Abscesses.-Most frequent in Children, in whom they are the result of Lobular Pneumonia.-Diagnosis of Peripneumonic Vomicae is Difficult.-They may be confounded with Pleural Abscesses, 649-660 CONTENTS OF FIRST VOLUME. XXVII LECTURE XXXVI. TREATMENT OF PNEUMONIA. Simple Pneumonia without any Complication.-Expectant Medicine.-Local and General Bleeding.-Blisters.-Antimonial Preparations, particularly the Pre- cipitated Sulphuret [Kermes] in large doses according to Rasori's Method, 660-670 Erysipelato-phlegmonous Pneumonia, .... . . 670-671 TREATMENT OF PNEUMONIA COMPLICATED WITH DELIRIUM, BY PREPARATIONS OF MUSK. Musk not indicated in all cases of Pneumonia accompanied by Delirium.-Distinc- tions Essential to establish in relation to this point, .... 671-676 PNEUMONIA OF THE SUMMIT. Not necessarily accompanied with Delirium.-Delirium may also occur in Pneu- monia situated in the Centre or Base of a Lobe.-Pneumonia of the Summit is not necessarily more dangerous or more tedious; but this statement requires limitation in respect of Tuberculous Patients,. 676-677 LECTURE XXXVII. PARACENTESIS OF THE PERICARDIUM.. Cases.-Historical Summary.-Harmlessness of Tapping the Pericardium and In- jecting Solutions of Iodine.-Better to make the opening with the Bistoury than with the Trocar.-Dropsy of the Pericardium almost always associated with some other diseased state, particularly with the Tuberculous Diathesis.- Paracentesis affords relief and prolongs life placed in immediate jeopardy, 678-699 LECTURE XXXVIII. ORGANIC AFFECTIONS OF THE HEART. General Considerations.-Insufficiency of the Aortic Valves is the most serious of all the Lesions of the Cardiac Orifices.-Dropsy treated by Purgatives.-Diar- rhoea sometimes requires to be arrested : at other times it constitutes a natural crisis which ought not to be interfered with.-Diagnosis of Affections of the Heart is often difficult.-Embolism and its Consequences, . . . 699-715 XXVIII CONTENTS OF FIRST VOLUME. LECTURE XXXIX. ON VENESECTION IN CEREBRAL HEMORRHAGE AND APOPLEXY. Apoplexy is not to be confounded with Hemorrhage.-Cerebral Hemorrhage rarely sets in with Apoplectiform Phenomena, properly so called.-Apoplexy may be the expression of various Grave Lesions of the Encephalon.-Value of Facial Hemiplegia in Hemorrhage.-Inutility of Venesection, of Bloodletting in gen- eral, of Purgatives and Emetics in Hemorrhages and Apoplexy.-Differential Diagnosis between Softening and Hemorrhage.-Value of Certain Signs with regard to Prognosis,715-726 LECTURE XL. ON APOPLECTIFORM CEREBRAL CONGESTION, AND ITS RELATIONS TO EPILEPSY AND ECLAMPSIA. g 1. The Existence of Cerebral Congestion is not contested; but it has been singu- larly Abused, in order to explain Cerebral Phenomena in the Production of which Congestion plays no part whatever.-Sudden and transient Fits of Apo- plexy are among these, and the so-called Apoplectiform Cerebral Congestions are oftener connected with Epilepsy than is generally believed.-A few Con- siderations on. the sudden and irresistible Impulses of Epileptics in general, and on the inferences to be drawn from them in a medico-legal point of view, 726-732 § 2. Apart from Epilepsy, a great many Cases of so-called Cerebral Congestion, in what is popularly known as the coup de sang (ictus sanguinis'), belong to the Class of Internal Convulsions, of Vertigo occurring in connection with Disease of the Internal Ear, and with Dyspepsia.-What happens in the Brain in these Attacks is much more nearly allied to Syncope than to Congestion.-The Apo- plectic Stupor of Cerebral Hemorrhage, of Epilepsy, and Eclampsia, is due to what I have called " Cerebral Surprise."-Epilepsy and Eclampsia present re- markable analogies.-The condition of the Cerebro-spinal Axis, of which they are both an expression (a condition unknown in its essence), suffices for Pro- ducing Stupor.-The Cerebral Congestion, which in Attacks of Epilepsy and Eclampsia may be pushed as far as Hemorrhage, is a Secondary Phenomenon, 733-740 LECTURE XLI. ON EPILEPSY. § 1. Cases of Epilepsy..-Description of a Fit.-How to recognize the Feigned Dis- ease.-Three Stages : Tonic Convulsions, Clonic Convulsions, and Stupor.- Synonyms : Morbus Major, Morbus Comitialis, Morbus Herculeus, Falling Sickness, Haut-mal, &c., &c.-Sequel®: Subcutaneous Ecchymoses, Cerebral Hemorrhages, &c.-Cerebral and Spinal Lesions are Effects, not a Cause of Epilepsy.-Exciting Causes.-Status Epilepticus.-Petit-mal, _. . 741-752 CONTENTS OF FIRST VOLUME. XXIX § 2. Epileptic Vertigo.-Aura Epileptica.-Partial Epilepsy.-Angina Pectoris.- Painful Spasm of the Face, 752-760 § 3. On the Relations of Epilepsy to Insanity, 760-769 % 4. On Hereditary Taint as a predisposing Cause of Epilepsy.-Influence of Mar- riages of Consanguinity,.' 769-775 % 5. Diagnosis between Epilepsy and Eclampsia.-Transformation of Eclampsia into Epilepsy.-Differential Diagnosis from Hysteria.-Symptomatic Epilepsy.- Treatment of Epilepsy, 775-783 LECTURE XLII. ON EPILEPTIFORM NEURALGIA. The Branches of the Trigeminal or Fifth Cranial Nerve are those generally Affected.-The Neuralgia is in most cases Accompanied by Partial Convul- sions.-Is nearly Incurable.-Analogy between it and the Aura Epileptica.- Differs from Epilepsy, although sometimes Observed in Epileptics.-Is Re- lieved by Section of the Nerve and by large doses of Opium, . . 783-791 LECTURE XLIII. INFANTILE CONVULSIONS. The Organic Alterations are an Effect, and not the Cause, of the Convulsions.- Yet those Secondary Anatomical Lesions should be taken into consideration.- Predisposing, Hereditary, and Acquired Causes.-Exciting Causes.-The Con- vulsive Paroxysm comprises Two Stages, one of Tonic Contraction, and the other of Clonic Movements.-A Third Stage, that of Collapsus, is an Effect of the Convulsion itself.-Convulsions present Infinite Varieties.-General Con- vulsions.-Partial Convulsions.-Status Convulsivus.-Inward Convulsions.- Thymic Asthma.-Sequelae.-"When Death occurs, it is by Asphyxia, or by Nervous Syncope.-Prognosis.-Treatment, 791-809 LECTURE XLIV. ECLAMPSIA OF PREGNANT AND PARTURIENT WOMEN, . 809-813 LECTURE XLV. ON TETANY. Causes : the most frequent are Nursing and the Puerperal State ; Influence of An- tecedent Diarrhcea ; Effect of Cold.-Description of the Disease : Three Arbi- trary Forms.-Mild Form: Local Manifestations are alone present, and the Symptoms are very Slight.-Intermediate Form : the Contractions become general, and Spread from the Extremities to the Muscles of the Trunk and Face, while General Symptoms are superadded to them.-Grave Form : Vio- lence of the Convulsions.-A Fatal Case.-Prognosis generally not Grave.- Pathological Anatomy very little known.-Nature of the Disease.-Differen- tial Diagnosis.-Treatment,814-825 XXX CONTENTS OF FIRST VOLUME. LECTURE XLVI. ON CHOREA, 825-827 ST. VITUS'S DANCE. Reason why the term St. Vitus's Dance appears to me better than that of Chorea. -Predisposing Causes: Age, Sex, Hereditary Influence.-Pathological Condi- tions : Chlorosis, Tubercular and Strumous Diathesis, Rheumatism.-Exciting Causes : Emotions, Fright.-Description of the Disease.-Antecedent Phe- nomena.- Convulsive Phenomena.-Their Specific Character.-Paralysis.- Disorders of Sensibility.-Impairment of the Intellectual Faculties.-The Complaint is usually Curable.-Its Mean Duration.-It may Terminate in Death, and How.-Pathological Anatomy throws no light on it.-Influence of Intercurrent Febrile Diseases on the Course of the Complaint.-Relapses and Recurrences : their Duration is Less than that of the Previous Attacks.- Treatment: Cold and Warm Baths, Sulphur Baths, Gymnastics.-Internal Remedies: Tartar Emetic, Strychnine, Opium in Large Doses in Grave Cases, Hygienic Measures, 827-853 OF THE DIFFERENT FORMS OF CHOREA. Chorea Saltatoria.-Methodical or Rhythmic Chorea.-Tic-douloureux {Chorea Neuralgica').-Tic Non-douloureux.-Writer's Cramp {Chorea Scriptorum, Functional Spasm of Dr. Duchenne, de Boulogne), .... 853-863 LECTURE XL VII. SENILE TREMBLING AND PARALYSIS AGITANS, . 863-870 LECTURE XLVIII. CEREBRAL FEVER. Instances of Different Forms of Cerebral Fever.-Description of the Disease : Three Stages which are generally Distinct.-Premonitory Stage, Characterized by a Group of general Phenomena, which may be seen in other Diseases, but which are never so Marked and never so Prolonged as in this Complaint.- Second Stage : Absence of Fever ; the Pulse becomes remarkably Slow, and the Breathing peculiarly Irregular.-This Irregularity of the Respiratory Move- ments is a Sign of Great Value.--Differential Diagnosis between Cerebral Fever and Typhoid Fever.-Third Period: the Pulse quickens again, and often to an Extraordinary Degree.-Prostration, Delirium : Convulsions, at first Partial, then General; Paralysis.-Cerebral Fever is nearly always, not to.say always, Fatal, whatever be the Treatment adopted.-The post-mortem Appearances are more indicative of Cerebro-meningitis than of Meningitis.- Whether Tubercular or not, the Complaint runs the same Course.-Chronic Hydrocephalus.-It is not a consequence of Cerebral Fever, . . 871-890 CONTENTS OF FIRST VOLUME. XXXI LECTURE XLIX. CROSS-PARALYSIS, OR ALTERNATE HEMIPLEGIA. In most Cases it is owing to a Lesion of the Pons Varolii, but it is not an Absolute Sign of such Lesion. It should not be confounded with Glosso-laryngeal Paralysis, 891-895 LECTURE L. FACIAL PARALYSIS, OR BELL'S PARALYSIS. Facial Hemiplegia: its Causes and Symptoms.-Contraction of the Muscles con- secutive to Paralysis of one side of the Face may be mistaken for Paralysis of the opposite side-Treatment.-Double Facial Paralysis, . . . 895-907 LECTURE LI. ON GLOSSO-LARYNGEAL PARALYSIS, . . . 908-925 1N T R 0 D U C T10 N. WHAT IS CLINICAL MEDICINE? Gentlemen : Before speaking to you about the patients in the wards, I require to tell you what I mean by " clinical instruction," both in respect of the teacher and the taught. To me it is no doubt pleasant to see numer- ous pupils crowding round the beds, and filling the benches of the theatre, but it is very much more pleasant to have the consciousness of discharging a useful mission, and of leaving on the youthful mind impressions which will by and by yield fruit. Professor and pupils must conform to certain conditions, without attention to which clinical instruction will necessarily be sterile. Although the clinic is the copestone of medical study, I would not wish you to suppose that it ought to be deferred till you have nearly reached the close of your curriculum as students. From the day on which a young man wishes to be a physician, he ought to attend the hospitals. It is essen- tial to see-to be always seeing-sick persons. The heterogeneous materials, though amassed without order or method, are nevertheless excellent ma- terials ; they are for the present useless, but you will, at a later date, find them stored in the treasure-house of your memories. I am now an old man, yet I remember the patients whom I saw forty years ago, when on the threshold of my career. I recollect their principal symptoms, their anatom- ical lesions, and the numbers of their beds; and sometimes the names even of the patients come into my mind, after that long interval of time. These recollections are of service to me; they still afford me instruction, and you sometimes hear me appeal to them at our clinical meetings. For these reasons, then, I ask the young student to attend every day an hospital visit. I care little whether he commence with medicine or surgery. Still, it appears to me more profitable at first to frequent the medical than the surgical wards. The young man is attracted by the display of surgical operations; the pomp of preparation, the dexterity of the surgeon, the immediate conquests which he achieves, combine to strike and bewitch the'youthful imagination; but, so far as instruction is concerned, the per- formance which he has witnessed is barren. Before one can understand the mechanism of the reduction of a fracture or dislocation, a considerable knowledge of anatomy and physiology must be acquired ; but the pupil who is present at those delicate operations, in which the performer does not make the slightest cut without bearing in mind the minutest anatomical details, cannot understand the amount of skill, coolness, and intelligence required to attain results, which, to the operator are immense, but which are inappreciable by one who has everything to learn. I have always ob- served that young men were more delighted by those operations which de- VOL. I.-3 34 INTRODUCTION. mand no more intelligence than is required by a butcher's lad to cut up an ox, than by those wonderful proceedings, those delicate and thoughtful manipulations, the ability to perform which constitute the real surgeon, and which strike with admiration the thoroughly informed who can under- stand and appreciate them. You will not, then, derive real benefit from frequenting the surgical wards till you have been initiated in anatomy, while, for studying the rudiments of medicine, it will suffice to have ac- quired some superficial acquaintance with physiology. You will soon become accustomed to see patients, to read in their coun- tenance the gravity of their diseases, to feel the pulse and appreciate its character, and you will learn the first elements of auscultation and percussion. You will soon become acquainted with the chief functional disorders, and be able to recognize the modifications of the secretions and the excretions. You will see in the dead-house some of the relations between the lesions found on dissection, and the symptoms or signs observed during life. At the end of some months you will have learned many things which, if not then acquired, you would be obliged to learn at a subsequent stage of your studies. Let me repeat that these ideas will, in truth, be only confused; but still you will find as you go on that the lessons, and particularly the familiar conversations of your masters and fellow-students, will have helped you to arrange some of the disorderly materials; in any case, you will have learned enough to render attractive your future studies. The public think it strange to hear physicians speak of the fascination which accompanies the study of our art. Literature, painting, and music, do not yield an enjoyment more keen than that which is afforded by the study of medicine, and whoever does not find in it, from the commencement of his career, an almost irresistible attraction, ought to renounce the inten- tion of following our profession. But the very attractiveness of medicine when studied at the bedside, has, nevertheless, sometimes slight drawbacks. The young student who passes an hour or two every morning in the wards of an hospital, experiences no great pleasure in resuming his place at the dissection-table. I admit that, for the novice, the study of anatomy is often irksome. It is a study which forms an essential part of the education of the physician and surgeon; but its utility is not at once perceived, and the toilsome, disgusting nature of the occupation, combined with the sustained attention which is necessary, fatigue the student; in fact, it is only the inflexible requirements of the examiners which prevents the majority of our young recruits from deserting the dis- secting-room ; the facility and the charm, then, of hospital study may become a danger, by leading students to neglect necessary and laborious branches of their education. The short time which you can devote to medicine, makes it very diffi- cult for you to study the accessory sciences. It is important, therefore, that before entering upon the medical curriculum, you should possess a knowl- edge of chemistry and physics sufficient to enable you to understand their applications to medicine; but I would deeply deplore your losing time in ac- quiring too extensive a knowledge of chemistry. Although chemistry renders very restricted services to medicine properly so called, although in general the most eminent chemists have been poor physicians, and sterling practi- tioners have always been sorry chemists, I would not the less admit the desira- bility of the physician having a very extensive knowledge of chemistry, were it only for the purpose of convincing him of the vanity of the pretensions of the chemists, who believe that they can explain the laws of life and of the- rapeutics, because, forsooth, they know the nature of some of the reactions which take place in the living body. As the lifetime of an intelligent man WHAT IS CLINICAL MEDICINE? 35 is hardly long enough to enable him to make himself acquainted with medico-chirurgical pathology and therapeutics, why should the student be asked to distract his attention with accessory studies, which, without being wholly useless, are nevertheless too unimportant to be pursued at the sacrifice of physiology, clinical instruction, and therapeutics, the subjects without a knowledge of which no man can be a physician ? Gentlemen, far from me be the thought of instituting a suit against the accessory sciences, and against chemistry in particular. I only condemn an exaggeration of their importance, their pretentiousness, their being mixed up with our art in an inappropriate and impertinent manner. -I do not know any one who denies that all the compositions and decompositions, all the molecular movements, all the manifestations of force belonging to vegetative life are physico-chemical; but if among these manifestations there be some which are governed by laws similar to the laws which govern dead matter, there are others (and they are the most numerous, the most important, the most essential to living matter), which obey quite different laws-laws which perhaps chemistry may some day discover, but which for the present remain autonomous, special, unexplained, inexplicable, and when confronted by which, the vanquished chemists and natural philoso- phers ought to pause. I have no objection to their holding the opinion that, in a future, more or less remote, they may be able to subordinate vital to chemical laws, but in the meantime, I wish them to be modest, and not to pass off their hopes for ascertained truths. I am quite willing to con- fess my ignorance as a chemist, but only on condition that chemists admit their ignorance as physiologists and physicians. I should be sorry to have to repeat to you discussions which, leaving every one in possession of his own opinions, have hitherto led to no result. I agree with the majority of physiologists and physicians in believing that the acts of organic life, and a fortiori, those of animal life, are subject to laws which in the meantime, ought to be regarded as essentially different from those which govern inorganic matter. Take two eggs, laid by the same hen, with an interval of some days between them, the one having received, and the other not having received the fecundating influence of the male. I beg the ablest chemist to tell me what analysis will tell him about the differ- ence between these two eggs. In both there is albumen, fat, earthy phos- phates, chlorides, and a'little iron. Has the chemist discovered wherein con- sists the chemical and physical difference between these two eggs? Will he admit with me, and with everybody else, that their composition is identical? There is, however, a very small difference, quite insignificant, the chemist tells us: they say that one is organic matter without vitality, while the other is absolutely identical organic matter, endowed with a property which, for want of a better name, we call life. Let us, nevertheless, see how each egg is affected by the same influences. We place them below a hen, under ex- actly the same conditions as to light, temperature, and moisture. In a few days, the non-fecundated egg, obeying the laws of dead organic matter, will be putrescent, while the other will contain a contractile tube filled with blood: in a few days later, this minute vessel will consist of four compart- ments separated by valves, and will become a heart receiving and sending forth blood through separate channels. The calcareous phosphates will take their appointed places, lengthening out as jointed levers, moulded as cavities, or extended as plates. The albumen will be distributed in the blood, muscles, parenchyma, and membranes: the iron and the salts will take their own special and predetermined places. " The retort has its mysteries," say chemists, but it appears to me that the fecundated egg has other and somewhat stranger mysteries. The talis- 36 INTRODUCTION. man which exists in it, but not in the chemist's retort, is life; the singular properties of living matter are vital properties, and say what you will in opposition to them, you will be obliged to admit their existence. If you kill the living matter, before incubation, by a violent shake, by elevating or lowering the temperature a little too much, or by the electric spark, and treat the non-fecundated egg in the same manner, the condition of both will become identical from that time, and the course which each will follow will thenceforth be similar. There will, however, be nothing less than there was before, except that trifle, which it is not worth while to take account of, life, or-if you like the term better-vital properties. But the evolution-power of the embryo, in which the vital force appears so marvellous, continues to exist, perhaps, in a more simple but in a not less evident form. When the animal is fully formed, it is no longer from an amorphous material that the tissues select their constituent elements, but from a liquid of determinate composition-from the blood. Hence- forth, it is this liquid which provides for all the aggregations, all the de- compositions, and for that incessant movement constituting, in point of fact, qne continuous evolution, which is, to the observer, less extraordinary than the first evolution, only because it is accomplished by completely formed instruments. Is it possible that there exists one man so insane as to deny that all the movements of composition and decomposition are something more than mere chemical manifestations. Combinations may be ternary or quater- nary, but they are not the less only chemical combinations; and I do not know that any one has ever denied this statement. From this point of view we are all iatro-chemists, with this distinction, that the worshippers of chemistry hold that the changes in living plants and animals take place in accordance with the laws of inorganic chemistry, while we maintain that the laws which preside over organic chemical action are of a special char- acter, and in particular, that in living organisms chemistry is controlled by special powers, which give it a special direction, placing it under con- ditions wholly different from those observed in matter destitute of life. That which strikes me as most remarkable in the fecundated egg, as well as in the fully formed animal, is not so much the complex chemical com- binations which take place at so small a cost of effort, as the elective affini- ties which manifest themselves, if I may be permitted so to express myself. In the amorphous albuminous mass which we call the egg, each principle, without any straying, takes its proper place: here, we have the calcareous phosphates, and there, the phosphorus, the fatty matters, the fibrin, the hair and nails, each finding their places with an order and method which clearly demonstrate the existence of properties different from those of inor- ganic matter or dead organic matter. Again, in that living organism, the fecundated egg, chemical actions which are all decreed, regular and of un- erring perfection, concur in promoting one object; but in the non-fecundated egg, there is chance, and that chaos of chemical reactions which manifests itself in dead organic matter. Chemistry plays its part in both instances, but that part is very different in each : and we must admit that there are special properties in the one case, because in it there are special results. Gentlemen, forgive me for having made a digression which, perhaps, you have found out of place, and too long. The excessive admixture of physico- chemical science with our art has produced so much evil, and is calculated to lead astray so disastrously young men commencing the study of medi- cine, that, in spite of myself, I feel that I am exaggerating the danger, and withdrawing you from studies to which you are indebted for useful infor- mation. WHAT IS CLINICAL MEDICINE? 37 Let us, then, return to our clinical inquiries. The living organism, both in animals and vegetables, has properties, in virtue of which it accomplishes the functions of nutrition. Besides, there exist, especially in animals, organs which incontestably establish a co-ope- rative purpose in the different parts of the living economy. In health, the different functions are performed with regularity; but in disease, the func- tions of nutrition and relation are modified. Whatever the nature of these modifications may be, they do not fundamentally change the properties of living matter; they only change its modifications. The properties remain unaltered ; " Quae faciunt, in homine sano, actiones sanas, eadem in aegroto, morbosas." When a morbific element is introduced into the economy, when it circu- lates with the blood, it there behaves itself like the different principles which are daily received into the system by digestion, absorption, and res- piration. Some of these principles are wholly assimilated, and, conse- quently, are of the nature of food, while others contain materials which rebel against assimilation, and which, if absorbed, have to be eliminated by the different emunctory channels, and rejected by the stomach or intestinal canal, if they have been swallowed. You perceive that things proceed in natural order up to that point; that is to say, all goes on naturally in re- spect of alimentary substances containing non-assimilable principles which are necessarily expelled. But if among these non-assimilable principles there be anything which produces an active topical irritation, there will follow local inflammation, exercising an immediate or remote influence upon different functions, according to the more or less intimate degree in which the part affected is connected by sympathetic relations with other parts. If the agent, in addition to its irritant properties, possess the power of vitiating or altering the quality of the blood, or of acting directly or in- directly on the regulating power of the nervous system, you can conceive the greatness of the perturbations which will be produced. But let us return to physiology. To sum up the preceding remarks, be- lieve me that the relative vital processes, whether more or less complicated, ceaselessly demand organic modifications which have their counterparts in pathology, just as pathological phenomena have their correlatives in physio- logical functions. What is the difference between the therapeutic stimulant and the alcohol or coffee which we imbibe daily at meals ? What is the difference between the dulling drugs prescribed by the physician, and the enervating fumes of tobacco which constitute in the present day a part, so to speak, of the life of the majority of the male population ? Wherein con- sists the difference between food charged with spices, incorporated with highly stimulating condiments-between meat which the epicure esteems, because it is in an advanced stage of putrescence-and the morbific causes which excite and shatter the nervous system, or alter the constitution of the blood ? Animals and plants, however, are constituted with the power of selecting from food that which is suitable, and rejecting that which is injurious to them. This effort of selection is accomplished at the cost of an only tran- sient inconvenience. The feverishness which accompanies digestion, is indeed, within certain limits, a pathological condition. It occurs several times a day without injury or lasting disturbance of the economy ; but if there be an alteration in the functional instruments, the duration and vio- lence of the disturbance reaches a state of disease ; and likewise, if the in- struments be perfect, but the work which they have to perform be beyond their organic power, an analogous disturbance supervenes, which is disease. We can imagine that, in that condition which we designate inflammation 38 INTRODUCTION. (la fluxion), and inflammatory engorgement, as well as in the formation of all kinds of plastic deposits, each organic cell is in its ultimate analysis an animal in the most elementary form, with a mouth represented by the artery, an anus represented by the vein, and an amorphous mass represented by the parenchyma of the cell; the blood, the nutritive element, is its food. In the physiological state that which takes place is simply composition and decomposition, the tissue, at the same time, preserving its integrity, and undergoing no changes which are not purely physiological; but if the blood carries vitiated materials, or materials which are too actively nutritious, it is evident that something will take place in it analogous to that which I described as occurring in the alimentary canal under similar circumstances. The unsuitable materials will be badly received by the organic cell, and will produce within it morbid disturbances ; they may either remain in it too long, or be expelled from it too quickly ;*or they may develop within it new phenomena of anomalous secretion. The duration of the disturbance set up is in proportion to the degree in which the materials are antipatheti- cal to the living cell, in proportion to the degree in which they are irritat- ing or too abundant. When the extraordinary afflux ceases, the properties of the tissue, for a time oppressed and disturbed, return to their normal state, the cure being accomplished in the same way that a return to health takes place after a fit of indigestion. It is in this sense that we ought to understand the famous Hippocratic theory of the coction of humors in dis- ease ; to the mind of Hippocrates, normal digestion was nothing more than a " coction and he regarded the coction which takes place in disease as a process analogous to healthy digestion. I am perfectly aware, gentlemen, that here theories leave much to be desired ; and I know that they are not more acceptable, when the subject under discussion is the great class of nervous diseases which holds so large a place in pathology; but, as I have already had the honor of telling you, in studying the physiological processes assigned to the nervous system, and the hygienical causes which act more particularly on that system, one soon perceives that ultimately the laws are the same which, in the circumstances specified, preside over physiological and pathological processes. What I have said to you in respect of diseases cum materia, of diseases in their relations to the phenomena of digestion and nutrition, also apply to ner- vous diseases in their relations to the senses and the different manifesta- tions more particularly originating in the nervous system. We have just seen that, in accordance with the laws of physiology, nutrition cannot be accomplished in a certain time and manner without giving rise to transient perturbation. We have seen that the functional aptitudes suffice for the restoration of order. If we go a little higher, we arrive at the state of disease; the functional aptitudes remain the same ; but a little more work, or some more toilsome exertion, are required to accomplish the pathological than the physiological function. Though the apparatus be sufficient for the work, though it does not the less possess the fitness and power bestowed upon it by nature, it requires more time for performing the pathological function, and meets with more difficulties in accomplishing it. If these difficulties are not insurmountable, a cure takes place-a cure wrought out in virtue of the innate properties of the matter aggregated and constituted in organs ; if, as unfortunately too often hap- pens, the difficulties are insurmountable, the result is the destruction of the function or the organ, or the destruction of both. It is not the less true that, to living tissues, to organs, to apparatus, certain powers are allotted, which survive the most violent shocks, and by the instrumentality of which powers, physiological and pathological processes are accomplished. It is WHAT IS CLINICAL MEDICINE? 39 correct, therefore, in a figurative sense, to say that nature has a tendency to effect a cure; but this statement does not imply that the tendency may not be met within the living body by the insurmountable obstacles of a worn-out state or a destruction of organs ; and external to the body, by a violent and malignant operation of morbific causes. He who is a thorough believer in this inherent power of tissues, will be less disposed to act, more circumspect in his therapeutic assaults, and will better understand that the physician sometimes discharges his duty best by restricting himself to observing and directing the vital forces. We have too much faith in. our- selves, and are too distrustful of that which I metaphorically call nature. We do not sufficiently recognize the fact that, when once the stir-up is given-pardon the vulgarity of the expression-things resume their normal style, and that there is nothing which the physician ought more to respect than the return of the natural functions to activity, as that will do more to bring about a cure, than all the agents of the materia medica. When under the influence of that particular modification of the economy, which (for want of a better name) we call inflammation, an effusion of serosity and plastic products takes place into the pleural cavity, we try to interfere, and-we will say it-we interfere usefully in a tolerably large number of cases; but it is as to the limits within which successful interven- tion is practicable that the majority of physicians are most ignorant. To look at the pertinacity of our medications, the incessant and tumultuous activity of our therapeutics, one would suppose that it is our duty to dis- trust nature, that we are jealously desirous of doing all ourselves and with- out her aid. When inflammation of the pleura is at an end, there remains a something, and that something very plainly appreciable by ausculta- tion and percussion-I mean effusion : this will occupy our minds, both be- fore and after it occurs, more than the local lesion which gives rise to it. We are slow to believe that when the inflammatory orgasm has ceased, the great organic cell, which we term the pleura, can return to its normal aptitudes, and perform that function which elementary organic cells are constantly performing in the process of nutrition. From that time, the pleura proceeds to absorb and digest the morbid products which it contains; and this it is generally able to accomplish, though in most cases the work is slowly done. I at once admit that paracentesis of the chest will save the pleura a great deal of work, just as I grant that copious vomiting is the best and most salutary of remedies when the stomach is surcharged; nevertheless, when the effusion is not excessive, when there is no irremediable tubercular deposit in the lungs or on the surface of the serous membrane, the natural innate functions of the pleura suffice for the absorption of the effused fluid and the accomplishment of a complete cure. In the same category, there is a multitude of chronic diseases. When an exostosis supervenes under the influence of the syphilitic poison, beware of supposing that the lesion ought to be pertinaciously pursued as long as the bone and periosteum remain swollen. The venereal virus has been long ago conquered, and the exostosis, or other lesions which remain, are only evidences of its past action. If the practitioner discontinue his treat- ment, the functions of assimilation, distributed to all the tissues, will prove sufficient to cause the disappearance of that which a too protracted medi- cation would, perhaps, have allowed to remain. Homoeopaths, very unin- tentionally and unwittingly, I admit, came opportunely to teach us to recognize the inherent forces of the living economy. Their successes, based with precision upon cures which they attribute to themselves, but which belong exclusively to nature, have been useful lessons to us. They have taught us to rely a little less on ourselves and a little more on the wonder- 40 INTRODUCTION. ful aptitude of the tissues and apparatus which constitute the animal machine. Again, gentlemen, do not forget that, in acute diseases, the time for use- ful treatment passes away rapidly, and that the expectant system soon finds its opportunity; and while we admit that in chronic diseases, the active, patient, reiterated interference of the physician may be advantageously continued over a long period, it is nevertheless sometimes very necessary to stay the hand, though'full of medicaments, and wait for a few days. It often happens that, when thus waiting, we see the awaking of the normal functions from a state of slumber, suffocation, and perversion, and have the good fortune to witness powerful manifestations of that which is called, without a sufficient comprehension of the term, the vis medicatrix natures. After a few months of study, the student ought to collect and write out cases ; he will thus acquire the habit of examining patients-of scrutinizing appliances and proceedings, of discriminating the symptoms which are of most importance and significance; in particular, he will learn to know the usual course of diseases-a kind of knowledge the most valuable which the practitioner can possess. I would fail in my duty if I did not lay strong emphasis on the words I am now going to utter-to know the natural progress of diseases is to know more than the half of medicine. But do not imagine, gentlemen, that it is easy to acquire this knowl- edge. There are many causes which place almost insurmountable obsta- cles in the way of this essential study. Most physicians entertain so exalted an opinion of the power of their art, as to believe it to be a dereliction of duty to abstain from treatment when they have before them an acute or chronic case. They institute active treatment, which of necessity disturbs the normal evolution of the disease; and even when this treatment is use- ful, it prevents them from ascertaining what would have taken place if matters had been let alone; when the treatment proves injurious the observer is left in a similar kind of perplexity. It must be granted that if we who have grown old in hospital and private practice, experience so much embarrassment in ascertaining the natural course of diseases, your difficulty will be much greater. You may well ask: Where is the thread to guide us through the inextricable labyrinth ? There is, however, a sufficiently easy method of acquiring this knowl- edge so important to the practitioner. Observe the practice of many physi- cians ; do not implicitly believe the mere assertion of your master; be something better than servile learners; go forth yourselves to see and to compare! If, in spite of treatment the most varied and opposite, you perceive that a particular malady generally proves mild, you may come to the conclusion that, in respect of it, physicians are impotent, and that the mildness depends less on the treatment than on the inherent nature of the disease. Having made good this point, look about in the hospitals, and you will quickly find a great many individuals who enter our wards after having spent the first days of their illnesses at their homes without any treatment, and you will discover that a large number of these patients have come into hospital just when convalescence was beginning. These cases are among the most important which you can observe. Compare them with those which you have seen treated in hospital, noting, in both classes, the duration of the disease and the rapidity of convalescence; if it become evident to you that the advantage is on the side of those who had no treatment, or that the influence of treatment of the most various kinds was null, nearly null, or absolutely hurtful, you have already learned that the disease in question is an acute one, in which nature is more powerful than the physician. Knowing, henceforth, the physiognomy of the disease WHAT IS CLINICAL MEDICINE? 41 when allowed to run its own course, you can, without risk of error, estimate the value of the different medications which have been employed. You will discover which remedies have done no harm, and which have notably curtailed the duration of the disease; and thus for the future you will have a standard by which to measure the value of the medicines which you see employed to counteract the malady in question. What you have done in respect of one disease, you will be able to do in respect of many; and by proceeding in this way you will be able, on sure data, to pass judgment on the treatment pursued by your masters. But it is evident that, to arrive at the point which I have now indicated you require daily attention, great love of truth, and much disinterestedness ; and these are difficult requirements. Affection for a teacher to whom you have long been in the habit of listening, may lead you too readily to be- lieve his assertions. I do my utmost to instruct you in what I believe to be the truth. Many of you, through a very natural feeling of deference (for which I am grateful), swear by the master's word, but I adjure you to seek yet other sources of instruction. I cannot do this as easily as you can ; it is only by reading that I can become enlightened as to my faults, and correct my erroneous opinions. In addition to reading, you have to guide you the observation of the practice of twenty hospital physicians, carried out in wards freely open to you, and by men whose advice is affectionately tendered. I am grateful when you bring under my notice observations which enable me to correct a mistake. Every year I am indebted to active, devoted young men for the opportunity of learning facts with which I was unacquainted, and reviewing erroneous views which I had long been teaching. In such opportunities I find a very agreeable reward for my efforts to be useful, and for the love I bear to my pupils. An understanding of the natural course of diseases is, then, as I have just said, the most important kind of knowledge which a young physician can seek after. It is with the aid of this compass that he steers with certainty through the difficult study of therapeutics, and is enabled to gauge the value of systems which succeed each other, only that they may in turn be speedily crushed by those which arise in their stead. There is no kind of practice, not even the fooleries of amulets and homoe- opathy, which may not yield you very useful instruction. As enlightened observers of the wonders attributed to secret remedies handed down in families, and fervently propagated by the believers in all religions (even by those who pretend that they are above such prejudices), you will see morbid phenomena defile before you in regular order, and without having anything wherewith to reproach your consciences, you will get ideas from what is passing, which you could not derive from your own researches. In point of fact, gentlemen, the physician, worthy of the priesthood to which he has devoted himself, has no right to place on one side his beliefs, even though they be false, that he may experiment upon his patients, and wait with curiosity to see what "expectation" can do for them. I have long been disposed to doubt the efficacy of medicine in acute pneumonia. Long ago I was tempted to leave nature to bring to a favor- able issue this disease, against which we are all disposed to act so vigor- ously ; but I have not yet dared so to act. Antimonials, emetics, and digi- talis, are my chosen weapons; and I should consider that I failed in my duty if, convinced as I am (perhaps erroneously) of their great utility, I did not employ them, that I might see in what manner nature would bring the disease to a conclusion. Abstinence from treatment answers admirably in mild diseases, and one may, without dereliction of duty, study their natural characters left undis- 42 INTRODUCTION. turbed by the intervention of art; but when there is danger, and we believe that we possess a remedy capable of removing that danger, conscience calls out to us to be doing, and brings us back to active treatment, even when, for a moment, we were about to yield to the seductive influence of a culpa- ble curiosity. This abstinence from interference which I have now censured, I, how- ever, entirely approve, nay, I proclaim its opportunity, when we have to deal with diseases against which all treatment has proved useless. In such cases, waiting teaches us at least one thing-that there are remedies which are hurtful, and that it is better to do nothing than to do mischief. But, in these very cases, if it be incumbent on us to refrain from treatment, that we may understand the natural course of the disease, wre must not too abso- lutely act in this way, and it is our duty to yield to those who, rightly or wrongly, believe that they have found a useful remedy. In incurable affec- tions, in affections which, though often curable, are grave, only yielding slowly, and after leading the patient through the greatest perils, therapeutic attempts are allowable, if they are corollaries from facts acquired under analogous circumstances, or from the successful experiments of others. When a patient runs an imminent and certain risk, it is justifiable, or at least it is excusable, to use every remedy, as in such a case we cannot make bad worse. Still, even in such cases, our therapeutic action must be defen- sible in theory and by an appeal to analogy. In presence of a child dying from suffocation in croup, it is intelligent, and accordant with powerful analogy, to act surgically, by affording an exit to the foreign body, and allowing air to enter below the obstruction in the larynx. Even when in such a case success does not crown the daring of the operator, his conscience will be absolved-and that is the great point. For centuries, paracentesis of the abdomen has been practiced for the evacuation of serous effusions. Why limit the employment of paracen- tesis of the chest to purulent effusions, as has till lately been the practice? Have I not been justified in acute pleurisy, with suffocation impending, when I plunged my trocar into the pleura ? Tracheotomy and puncturing the thoracic walls may prove useless, but still, if experiments be allowable under any circumstances, they are allowable in cases such as I have now indicated. So long as the man of art only makes experiments of this kind, he will be forthwith absolved by his own conscience (and that is the most impor- tant matter), and he will likewise be acquitted by his peers, who sit in judg- ment on his conduct; while, on the other hand, he will be condemned, and justly branded, if the experiment has been performed merely to gratify curiosity. But how much more blameworthy is the man who experiments in such a fashion in an hospital, where there is not that feeling of responsi- bility which often makes the private practitioner tremble; where there is no necessity to guard against a compromising of position; where patients are under absolute authority, and may for disobedience be dismissed from hospital, and turned adrift without asylum or succor. Strive, gentlemen, if you become witnesses of such misdeeds, misdeeds very rare, thank God! strive not to imitate them, lest you lay up for your- selves remorse to follow you to the end of your career. The physician has the right to experiment, but within certain limits, and under certain con- ditions which I have in part indicated, and which I desire still farther to explain. To understand properly the nature of this right, it is necessary to know the way in which practical and therapeutical views are acquired. I have already told you that most of the ascertained facts in therapeutics have proceeded from empiricism ; but I have taken care to let you under- WHAT IS CLINICAL MEDICINE? 43 stand that, although the primitive fact he purely empirical, its applications pertain to the intelligence of the physician who has discovered them. I have already told you that the intelligent physician perceives in a fact something which others do not see in it, and that it is in consequence of this that the fact enlarges his horizon. The inferences, however, from an elementary fact, will only have value in proportion to the extent to which experience is developed ; and experience can only be acquired by experi- menting. There is not a physician in the world, unless he be stupid and dishonest, who experiments without some other motive than merely to state results. He is led on by one or several facts already ascertained, and his tentative proceedings are in reality legitimized as he proceeds, either by anterior ideas supplied by chance or a combination of chance with atten- tive observation of facts. When the women employed in picking the stigmata of saffron have frequently had to complain of an excessive menstrual flow, the fact, one of common notoriety, could not but make an impression on the minds of physicians even the least intelligent; and from that point there was but one step to the discovery of the therapeutic action of saffron as an emmenagogue, and to a recognition of its power of frequently producing abortion. How did we come to try to repress the fleshy grariulations of a wound by the use of fused nitrate of silver? I do not know. But this practice, now so very common as to be left in the hands of medical novices and complete strangers to our art, has conducted practitioners to a course of experiment most prolific in results. Perceiving the resemblance between the catarrhal affections of mucous membranes and the granulating surfaces of wounds, they asked themselves whether it might not be opportune to apply the same caustic to mucous surfaces in such affections; trials, at first cautious, gave such encouraging results that the experimenters became bold, and solutions of nitrate of silver, at first applied to the pharynx and mucous lining of the mouth, have passed into everyday use in the treat- ment of inflammations of the mucous membrane of the nose, eyes, urethra, vagina, and even of the intestine. But if the most energetic of caustics was so evidently useful, might not one expect the same results from other substances of the same class as nitrate of silver ? The sulphates of copper and zinc, corrosive sublimate, and solutions of potassa, soda, and ammonia, tried in succession by different practitioners have responded favorably, and every day this field of experi- ment is becoming enlarged. It was soon perceived that the primary effect of these different agents was analogous to that produced by inflammation, and it was easy to understand that inflammation artificially induced in tissues already the seat of inflammation, led to a cure of the original in- flammatory attack. When this view was once acquired-a view, as you have seen, wholly due to experiment-there flowed from it the great thera- peutic principle of substitution, which, at present, rules supreme in medical practice. Thus it is that, step by step, therapeutics have become enriched ; it is thus that, day by day, experiment has added one fact after another to our store. When facts were seen to present analogies, and when their relations to each other became understood, groups of systems were formed, which afterwards expanded, and constituted a sort of body of therapeutic doctrine, doubtless leaving beyond its limits many unexplained facts, which must remain provisionally within the domain of empiricism, until they can, at a later date, be placed in a special category, and in a general system. Since the time of Sydenham there has assuredly been no advance in the 44 INTRODUCTION. treatment of intermittent fever, but the empirical opinion as to the powerful influence of the Peruvian bark is for all that not a crude notion, which it is sufficient to announce to give currency to with the general public. When the Countess del Cinchon, in the enthusiasm of her thankfulness, sent to Rome and Madrid the miraculous powder which had cured her of fever, the proceeding was only empirical; but Peruvian bark, when adopted and tested by Torti and Sydenham, became a remedy administered according to methods which it was the province of great physicians to determine. It is thus that even when a remedy is only applicable to a special disease, when no theory, no process of inductive reasoning has led to its employment, when, in consequence, it seems to belong exclusively to empiricism, the physician may still intervene with his intelligence, and institute a plan of treatment with a single medicine. He will not attempt to systematize, he will not be able to try even the smallest series of remedies, but he will form opinions as to the fitting time for using the special remedy, and as to the nature and duration of its influence in individual cases. He will regulate the doses as to their amount and frequency of administration. He will inquire into the means of rendering the remedy as inoffensive as possible, and he will study to discover, in the special symptoms of the case, whether there be any other indications which experience has already taught him to appreciate and fulfil. He will see that the anaemia which accompanies marsh poisoning yields with ease and certainty to the same remedies which succeed so well in chlorotic cachexia, and in such cases iron will become, in the hands of the physician, a useful adjuvant unknown to the empiric. The empiric can cure a paroxysm of fever; but it is the physician who cures the fever in the totality of its phenomena. It is the physician who makes a diagnosis, which it is impossible for the empiric to accomplish. To know that a patient has daily a paroxysm of fever com- mencing with rigors, and followed by heat and sweating, is knowledge of the commonest possible description-it is not diagnosis; but to know that the paroxysm of fever is unconnected with concealed inflammation, deep- seated suppuration, or an idiosyncrasy of the nervous system so common in some women-to know that it really is the manifestation of the influence of marsh miasmata-is a complex conception which can only exist within the domain of the physician. To appreciate the present influence of that poisoning, the influence which it has exerted and is destined to exert on the patient, and so to be enabled to adapt the duration and activity of the treatment, in accordance with the seriousness of the case, is beyond the resources of thef empiric. When it is necessary in simple or pernicious fevers to find the thread which leads up to a knowledge of the cause and essential nature of the disease; when it is necessary in a man who has a cough, difficulty of breathing in the horizontal position, bloodstained expectoration, and stitch in the side, to lift the deceitful mask and identify the intermittent fever which demands, imperiously and immediately, large doses of cinchona; when it is necessary to search out and discover the same indication of treat- ment amid a turmoil of violent symptoms in a protracted paroxysm of intermittent, which assumes the form of continued fever: when such con- tingencies arise, it is the physician who can alone usefully interfere, and the vulgar empiric, who has by chance stopped a fit of intermittent fever, is incapable of skilfully wielding the therapeutic weapon, even in the simplest cases, and if he has to do with forms of intermittent fever, in any degree complicated, he is unaware that he ought to employ the bark. Though empiricism, therefore, has furnished the original suggestion of the employment of cinchona, although up to this day we are quite unable WHAT IS CLINICAL MEDICINE? 45 to explain the action of this powerful drug, physicians have taken posses- sion of its unexplained action, have extended its beneficial sphere, and have, with a medicine which is empirical, instituted a system of treatment which is not empirical. The mission of the clinical professor is quite different from that of the professor of pathology. It is the province of the latter to trace system- atically the history of diseases-to point out their causes, nature, symp- toms, and treatment. He ought, as much as possible, to classify them in nosological order, and to present, as far as in him lies, an exact, well-defined picture, with which all the facts ought to correspond. The duty of the clinical teacher is not of the same kind. If a series of patients suffering from a similar affection present themselves in the wards, he will, no doubt, profiting by the occurrence, sketch a picture of the disease; but the descrip- tion given will be to a certain extent the recapitulation, the corollary, of facts observed; he will much more frequently have to study with his pupils the forms which the malady takes in virtue of particular medical constitu- tions of the atmosphere, and the idiosyncrasy of each patient, than to give a general picture. It will be specially incumbent upon him to show in what respect, and in what degree, the case under observation varies from classical descriptions : to point out the innumerable modifications in respect of the form, general character, and treatment of diseases due to the differ- ent conditions under which the patients are placed. In a word, while indicating the points in which the case conforms to classical models, he will describe with the most minute care the points in which it differs from them, endeavoring at the same time to show upon what these differences depend. It is precisely this kind of fundamental study which makes the prac- titioner. When the pupil has finished reading a treatise on medical pathology, he fancies himself already a physician ; but when confronted with a patient, he experiences the strangest embarrassment, and soon finds out that he has no ground to stand on. I do not speak only of embarrassment resulting from not being accustomed to the task-that he feels, and it is comprehen- sible that he should-but what I wish to tell you is, that the signs and symptoms have to him an air of utter strangeness. In his pathological treatises, the student has seen pulmonary tubercular phthisis delineated in striking features, the signs furnished by auscultation and percussion have been clearly and methodically laid down ; the author has insisted on deli- cate shades of variation, and on numerous exceptional circumstances; but these variations and exceptions have made little impression on the young man, though they are the very things which most frequently strike the true clinical observer as noteworthy in the incipient stage, and during the course of phthisis. He only who, during many months, and in the wards of an hospital, has studied tubercular phthisis in all its forms and in all its symptoms, can comprehend the immense difficulties which occasionally encompass its diagnosis. ' Gentlemen, I grieve to see beginners pressing round the beds, during the visits which immediately precede the lectures in the theatre, and absenting themselves from the wards on the days on which no public lectures are given. Let me tell you that such a course of proceeding is most unprofit- able. From the crowding, it is with difficulty, if at all, that you have been able to feel the patient's pulse or judge of the expression of his countenance; you have not ventured to fatigue him with an examination not to be re- peated without danger; whereas, in the services where there are few pupils, and even in the clinical wards on the days when there are no lectures, you have abundant leisure to interrogate and examine the patients, to ask 46 INTRODUCTION. explanations from your teacher and fellow-students: from examinations made in this way, you will carry away much most useful information, and it will be exactly such information as will enable you to understand the public discussions upon which the professors enter. I know how much room there is for improvement in the clinical teaching of the Faculty of Medicine of Paris. I know that young men are not sufficiently exercised in the examination of patients ; but whatever is want- ing in the official teaching, you can supplement by private instruction. Most of our young hospital physicians and surgeons-the agreges of the Faculty-who have nearly all obtained hospital appointments by competi- tive examination, are most anxious to direct students in the difficult study of diseases; and I must say that there is not a town in the world where this kind of instruction is given with greater zeal and liberality than in Paris. The immense hospitals of this capital are open gratuitously to Frenchmen and foreigners; every morning more than fifty services offer to industrious young men the most fertile and varied elements of study, and when students who have taken advantage of their opportunities come to attend the lectures of the clinical professors, they do so with profit. You must perceive that it is physically impossible for the clinical pro- fessor to exercise his pupils in auscultation and percussion, without a knowl- edge of which, however, they must remain unacquainted with a great many diseases. It is impossible for the clinical professor, when surrounded by a hundred and fifty or two hundred students, to teach them by methodically interrogating the patient, by discussing diagnosis, and pointing out treat- ment ; that can only be done in the private services, and in the clinical wards upon occasions when the professor is not obliged to enter the theatre at a stated hour, when he is not-surrounded by a crowd of pupils desirous to listen to the master's authoritative words, rather than to the hesitating talk of the timid scholar making his first professional attempts with patients. I cannot, gentlemen, sufficiently impress upon you that anatomy is never learned in a course of lectures; you must have the dead body, and it must, moreover, be a dead body surrounded by two or three students dissecting along with you, and one of whom is sufficiently intelligent to direct your proceedings; the clinic stands in the same category, and can only be learned in the hospital, with the aid of an interne, or chef de service, to teach you the art of putting questions, and of conducting methodically the examina- tion of a patient. I do not wish to speak to you here about the particular methods of in- terrogating patients ; the methods are very useful, but they are described in all your manuals. When I say that they are very useful, I wish, at the same time, to warn you against certain excesses in their employment, which always wound me deeply, and which you will never see me commit. You must remember, gentlemen, that hospital patients are poor creatures forced into our wards by distress and want. This fact ought of itself to be enough to conciliate our esteem and inspire our respect for them. With regard to men, I admit that we may act with less reserve than with women. Upon the whole, there is no great inconvenience, on the score of modesty or pro- priety, in uncovering a man to examine the surface of his body; but this examination is not permissible if it involve any risk to health; and here I must remark, that young men, when they strip patients for examination, too often forget that if the skin be covered with perspiration, it cannot, without great danger, be exposed to the contact of cold air. It is not per- missible to any one, not even for the sake of science, to prolong an exami- nation by auscultation and percussion to such a point as to exhaust the strength of the poor patient, and it is preferable, except in cases of impe- WHAT IS CLINICAL MEDICINE? 47 rious necessity, to leave an investigation incomplete, or to discontinue it till the evening or next morning, than to shatter a patient already pro- foundly prostrated. What I have just said applies to both sexes; but when the patients are women, the physician ought to remember that he has daughters and sisters to deal with, and never to allow his examination to assume the appearance of a culpable curiosity. The fallen women who enter the hospitals (and they are a very numerous class of patients) respect us only when we respect them. They judge us favorably from a reserved manner, for which, per- haps, they would elsewhere banter us; and I rather think that they carry away with them from hospital better feelings when they have been treated with as much consideration as the poor virtuous girls who occupy the ad- joining beds. It is quite possible to make, with the most perfect chastity, investigations, which seem to be the reverse of chaste; and, provided they are useful, espe- cially when they are so regarded by the patients, they are acceded to, and often even with gratitude. This is not a question of prudery, but simply one of good breeding. Bear in mind that the physician's chance of success in his difficult career is all the greater, the less he forgets, in his intercourse with patients, those rules of propriety which constitute the appanage of a good education. When your clinical studies are more advanced, when you can with real advantage make a digest of the knowledge you have acquired by systema- tizing your facts and cases, you will estimate more correctly than you now can, the value of the different nosologies and nomenclatures which so un- fortunately incumber our art. All nosologists have believed themselves to be in the right, all have pitied their predecessors, and all have been thor- oughly convinced that the classes, orders, genera, and species of diseases, were never grouped upon principles more legitimate and natural than those they have adopted. They have all been convinced that the new names which they have imposed on diseases form an imperishable nomenclature. What remains of nosologies and names? Nothing which has not been con- secrated by the assent of all ages, nothing which has not been adopted by the generality of physicians-nothing save the debris of all nosological systems and nomenclatures. People give themselves a great deal of trouble to torture the Greek lan- guage, and to heap up learned solecisms; they labor long to collect the most preposterous and fantastic names; but the good sense of the public executes prompt justice upon all these absurdities, and every one remains faithful to the old names, every one is satisfied with them, and every one understands them infinitely better than the barbarous words which it was wished to substitute for them. The manufacturers of nomenclature ought to look well about them, to see what are the terms which have survived, and which will survive for ages to come, continuing fresh, intelligible, and triumphant, in spite of the attacks of which they have been the object. I have no desire to defend such names as St. Vitus's dance [danse de Saint Guy'], epilepsy, hysteria, variola, scarlatina, hooping-cough [coqueluche], mumps [ottr/es], cholera, dysentery, and many others of the same sort which it would be tedious to enumerate; but tell me, gentlemen, whether it be not true that the term " danse de Saint Guy," although originally applied to another nervous affec- tion, has been used by all physicians, without a single exception, from the time of Sydenham downwards, to designate chorea, that fantastic neurosis which we so often see, in infancy and adolescence? I admit with you that the word "coqueluche" has, in a nosological sense, no meaning; but if it be 48 INTRODUCTION. a fact that, in the middle ages, this name was given to an odd sort of epi- demic pulmonary catarrh which made it obligatory on the sufferers to cover their heads with a kind of cowl called coqueluchon, it is equally true, that there is not a medical practitioner in the world, nor even a person com- pletely ignorant of our profession, who could make a mistake as to the meaning of the word " coqueluche." With you, I admit, that it is singular to have given pox the name of mutual love, invented by the shepherd of Fracastor: but nevertheless, we know what is meant by syphilis, and no name, were it ever so Grecian or barbarian, could be as good as that which all have adopted. Generally, people speak and write with a desire to be understood, and words which are applied with precision and exclusiveness to the things which it is wished to designate, are necessarily the best: and they are all the better the less they possess a nosological signification. The names which I have just cited are perfect, precisely because they imply no adhesion to a medical doctrine; that is the reason why they are excellent; and it is because their adoption does not constitute an article of pathological faith, that they have been universally adopted. We are, in the existing state of matters, at liberty to place diseases where we please in our list; but their nosological position implies neither the ne- cessity nor the propriety of changing names. We ought to be sufficiently modest and sensible to feel that we know nothing to the foundation, and that a synthetic, purely conventional term, is better than a descriptive one, which will always have the inconvenience of being too short to suffice for the requirements of description. When the immortal Jussieu classified plants, he was careful not to change the names of those which had been known for ages by the same names; he did not change names given by Tournefort and Linnaeus; he accepted those bestowed by Virgil, Theophrastus, and Dioscorides, as well as the popular appellations of flowers and trees. The apple remained the apple, belladonna kept its elegant name, mandragora retained the appellation which had made it so celebrated and formidable; he allowed the hemlock of Socrates to keep its ancient name, and was satisfied to classify vegetables according to affinities of structure and organization, always, when it was possible, respecting not only the names but even the epithets of Linnaeus. Where should we have been in the study of botany, if Linnaeus had refused to accept the names of Tournefort ? or if Jussieu had superseded those of Lin- naeus, and if Lamarck and Richard had conceived the idea of making them- selves celebrated, by substituting for the nomenclature of Jussieu one more to their own liking? It is evident that for new diseases new names must be found; but even in such cases, it is important to avoid nosological appellations. I much prefer the name of Bright's disease [maladie de Bright] to that of albuminous nephritis [nephrite albumineuse], not only because it is a homage to the illustrious English practitioner who was the first to give a good description of the disease, but still more because it imposes on me no doctrine nor opinion. Scarcely forty years have elapsed since the publication of the beautiful researches of Bright, yet in that time they have been followed by twenty theories in relation to the disease in question. Let diabetes mellitus [diabete sucre] retain the name it has so long possessed, and do not be in a burry, after reading the ingenious experiments of Claude Bernard, to give a name suggestive of irritation of the fourth ventricle or irritation of the liver; wait, and even when you are well informed regarding the cause and nature of diabetes, abide by the old name, which proclaims no foregone conclusion. Vulgar, universally received names are a sort of current coin, the denomina- tion of which one cannot alter, without introducing confusion into the com- WHAT IS CLINICAL MEDICINE? 49 merce of science. Rest assured, that systems of nomenclature (of which absurdity is the least fault) are not worth tainting the memory with; and earnest physicians ought to abstain from employing them, quite as much from respect to philology, as from a true desire to promote the progress of our art. It would no doubt be desirable that in medicine, nosology, that is to say the systematic arrangement of diseases, preceded clinical study and thera- peutics. If the system was true, the results would be necessary, and con- sequently, easy ; but unfortunately, many systems of nosology have been tried, and not one of them has survived its author. Clinical studies, par- ticularly therapeutics, are every day giving the lie most cruelly to the fun- damental propositions of these artificial sciences, and there is not a physician, who, even after a short practical experience, would not execute summary justice on all nosologies and nomenclatures. I admit that nosologies are an assistance to the student, at the commence- ment of his medical studies, just as the very false system of Linnaeus may greatly aid one in his botanical novitiate; but, gentlemen, when you know enough to be able to observe for yourselves [lorsque vous connaissez assez pour pouvoir reconnattre], allow me this sort of play of words-hasten to forget nosology, keep beside the bed of sickness, studying; studying each patient, each disease in each patient, proceed like the naturalist who studies the plant in its individuality, in all its elementary parts, and in all its varieties, ignoring classes, families, genera, and species, till his knowledge is sufficient to enable him to systematize, that is, till he can understand and discover sufficiently to establish analogies. I recognize the fact that you bring into the clinical wards your noso- logical theories; I even grant that they assist you at the commencement of your study of diseases; but still, I say, that in proportion to the extent to which facts become unravelled before you, in proportion to the degree in which you have examined them, and acquired an aptitude for comparing them, you must hasten to get rid of your scholastic trammels. Hasten to shake off the master's yoke; exercise your mind and judgment, and compel yourselves to systematize for yourselves ' By pursuing this course, you will by study either arrive at the same results as your predecessors, or you will form opinions from a different point of view : in either case your views will have become a personal acquisition. I do not wish you to efface from your memories all that you have heard in lectures nor to withhold belief from everything which you have not tested, but you must gauge by your own personal observation every doctrine which you are taught; you must collect and classify facts from your private practice, and afterwards systema- tize them. Though the systems which you thus construct will be far from embracing all the facts of medicine-not even all those which you your- selves have studied-the work of construction will teach you to perceive immediate and remote relations, and will furnish you with a sort of step- ping-stone, by the help of which you will be able to add other facts in suc- cession. It is by intellectual gymnastics such as I have now recommended, that you will attain a power of inductive reasoning unknown to those who, less through respect to those who have opened to them the gates of science, than through laziness or incapacity, servilely remain in ruts hollowed out for them by their masters. I like much to see in youth an independent, somewhat adventurous mind-a kind of mind which might in later years be a source of danger, when it was necessary to apply practically to patients the opinions formed by hospital study. The time for subordination comes apace; the pupil is about to become the physician! It is then that reading-the written experience of others- VOL. I.-4 50 INTRODUCTION. ought to come in aid of personal observation ; it is then that we form judg- ments upon the rules laid down by our predecessors and masters; it is then especially that we become modest, for we then very quickly perceive that all we have seen and estimated, has been seen and estimated by others, and by others more eminent than ourselves: we perceive that their generaliza- tions are of a higher and more prolific character than our own, and their systems better compacted; and when questions of medical or surgical the- rapeutics are under discussion, we soon discover that the plans which they recommend have been ripened and regulated by experience deserving the highest respect. But our reading and the lessons of our masters profit us in proportion as we have personal knowledge and ideas of our own at command. The de- ductions which eminent physicians have drawn from the facts they have observed appear quite natural, and we recognize in them opinions with which we are familiar, because they had arisen in our own minds, and the views which are new to us have less of novelty, from the fact that we are more naturally led up to them. A pupil feels pride in having arrived at con- clusions similar to those previously adopted by masters of the art, at having devised a therapeutic proceeding, or aiV- long known in practice. He then understands better how wortliyVff \respect are his pre- decessors who have done so much for the healing art, and his confidence in them increases in proportion tAXhe bf ideas wlpch he finds he has in common with them. The Mfi,n\who has always to the sugges- tion of another, and has not acted fronxhis owp promptings, will never be so eminent a physician, nor so .ardent of our great predecessors, as he who has been educated th their level, or who, though still young, has at least like them, sought'ouTnew paths. Between pupils and teacher, there ought to exist a species of reciprocity, in which the former receive the largest share of benefit, but in which the latter is also, to a certain extent, a gainer. Much have I congratulated myself that I had encouraged the young men by whom I was surrounded to think for themselves, to communicate their ideas to me, and to converse with me on what they believed to be their discoveries. How often have these ardent spirits reanimated my senescent mind, and shown me new horizons I How much have I learned in the familiar chats which take place in the wards! I have always felt pleasure in promoting and assist- ing the researches of my students ; and while my experience has not been useless to them, their enthusiasm has stimulated me, and has prevented me from rusting with that self-conceit of teachers, who are apt to fancy that they have nothing more to learn in the very difficult art of medicine. The man who is convinced that there is something to be gained, will always gain something; and in the most beaten paths something new can always be found, provided it be sought for with ardor and intelligence. Hence is it that when a man, ardent and young, yokeshimself to an idea- permit me to use this vulgar expression-he makes discoveries, arrives at new views, and teaches his masters things of which they were either igno- rant, or which they had only dimly seen. Doubtless, gentlemen, the young physician who takes this adventurous road, often loses his way, and is obliged, after long efforts, to retrace his steps; but rest assured he has gained something by the mental discipline undergone, and he will be the more apt to learn, the more frequently he has exercised his mind and ap- plied his attention to original researches. Let us inquire, then, whether the plans of study have always been bad, whether those pursued at the present day are the best, and whether they are adequate to establish medicine as a science. WHAT IS CLINICAL MEDICINE? 51 In considering these questions, I shall at once leave on one side the preparatory sciences, which bear the same relation to the medical art as the laws of light bear to painting, or stone-cutting to architecture; I shall, therefore, say nothing here of physics, chemistry, or natural history, which are unquestionably useful in medicine, but no more make the physician than the science of perspective makes the landscape-painter. Medicine is the art of curing, and it is nothing more than that; to cure is its object, and all our plans culminate in medico-chirurgical therapeutics. I willingly admit that some branches of accessory knowledge are good in themselves; but when the student has acquired them, I ask, how is he to become a physician ? Several methods of proceeding present themselves, but, without exception all of them, in all periods, and in all schools, have been based on previous observation of facts. So far as I know, it has never entered into the mind of any reasonable man to suppose that we can know without looking, or look without seeing. People, therefore, have always seen and always looked, when they wished to acquire information upon any point, or desired to systematize their knowledge. Attention necessarily implies comparing; and when comparison is not explicitly, it is virtually instituted. Thus, every physician has seen, looked at, and compared. It matters little to say that there is nothing to pre- vent him from seeing badly, from seeing with bad eyes, or with the eyes of other people, from looking at, and comparing things badly. What I here wish to establish is simply the fact that, everywhere and with all persons, the elementary procedure is the same. The subject, then, of methods of observation resolves itself into a consideration of how we ought to observe, how we ought to compare our observations, and how we ought to form our opinions. A conception of the nature of tangible objects is acquired by a simple perception of all the phenomena by which objects manifest themselves. This perception demands no intellectual effort; it requires attention and memory, and-as memory may prove treacherous-registration of the observed phenomena. When the blind man of Geneva made his marvellous researches into the habits of bees, he used the eyes of the most ordinary peasants, whose atten- tion he guided ; and these most ordinary peasants, the material instruments of his intelligence, enabled him to ascertain facts, and acquire general con- ceptions. All of you, after some months' experience, by adopting a formula of examination for each structure, function and organ, can fill up a sheet of observations in as complete a manner as your masters can ; to enable you to do this, the only requisites are patience, and the amount of intelligence re- quired for the drawing up of an inventory. Do not at that stage of your progress be too proud of your achievements, for you are then no better than the peasants who saw for Hubert of Geneva ; your eyes have seen, as it were, the industrious bee return charged with honey and pollen to build the hexagonal cells; they have seen a bee larger than the rest surrounded by general solicitude, and followed by a crowd of lazy bees of a different shape and color, ultimately undergo copulation, and observed that this was a signal for the massacre of all the non-working bees in the hive ; they have seen the sides of the respected bee swell out; they have seen this bee reposing in the cells which the working bees have constructed of different sorts ; they have seen the workers deposit honey in cells where something like a worm is moving; they have seen certain larger cells receive a richer tribute, and they have seen the worm contained in the latter become bigger than the others; they have seen these worms all at once assume new shapes, 52 INTRODUCTION. the larger becoming a cloud of bees of two very different forms, live together amicably till the smallest sized, which are armed, utterly exterminated the others; in a word, they have seen what is to be seen by paying attention. But the blind man understood what was seen ; nature refused him instru- ments, so he made them for himself, just as Galileo made a telescope. He fructified the crude, meaningless notions of those whom he employed, and traced with admirable sagacity the curious habits of those precious insects -habits of which hardly the slightest knowledge had been previously attained. God forbid, gentlemen, that I should here depreciate the value of the knowledge acquired by attentive and minute observation; the value of the results of such observation is immense; but I wish to point out that it has scarcely any claim to be considered an intellectual process. Without hewers of marble St. Peter's of Rome had never been built, but it would make me indignant to see a hewer of marble fancying himself almost a Michael Angelo. Since attention alone is necessary for the acquisition of facts in the rough, as the most commonplace minds are as well, or sometimes even better fitted for this kind of work, does it follow, gentlemen, that, scorning a modest oc- cupation, you should leave to others the collection of facts, contenting your- selves with their arrangement, interpretation and systematization ? Even in a man grown old in harness, that would involve such an amount of aris- tocratic assumption as to be hardly credible, but which,* to say the least of it, would be quite unparalleled in one who was only treading the first steps of his career. The sculptor does not take up his chisel to produce a Laocoon till after he has for a long time kneaded the clay, dashed out elementary forms in the rough, laboriously modelled shapes, and broken many a grav- ing-tool on coarse marble. Persons who have despised laborious beginnings, be they never so gifted and intelligent, are only spurious and imperfect artists. See, then, and observe for yourselves, for you cannot understand and utilize knowledge acquired by others, unless you possess some which is of youi' own personal acquisition. To the honor of all the great men who have rendered our art illustrious, it must be stated, that they have proclaimed the observation of facts to be an absolute necessity, and in the present day this necessity is more than ever admitted by those who preside over medical teaching. But if there be unanimity of opinion on that point, there is certainly no such concord as to the manner in which we ought to proceed to the interpretation of the facts observed. At present, there are two principal methods employed for the interpre- tation of medical facts, viz., the numerical, called the new method, and the inductive, called the old method. The former-the numerical method-has taken for its motto the celebra- ted sentence of J. J. Rousseau : " I know that the truth is in the facts, and not in my mind, which interprets them ; and that the less I introduce my own views into my interpretations the more sure shall I be of approaching the truth."* The second-the inductive method-is that which has till now been followed by all great practitioners, whatever may have been their other doctrines; and it is adhered to by the majority of the professors of our faculty. The numerical method, which took statistics for its basis, and which had * " Je sais que la verity est dans les choses et non dans mon esprit qui les juge; et que, moins je mets du mien dans les jugements que j'en porte, plus je suis sur d'approcher de la verity." WHAT IS CLINICAL MEDICINE? 53 already been introduced into hygienics by Parent-Duchatelet, was applied to the study of pathology and therapeutics by a man of undoubted scien- tific honesty, one endowed with an invincible patience, an ardent lover of truth-truth which he expected to attain with certainty. This method recognized the sovereign power of figures. Its advocates said " The phy- sician ought to restrain the flights of his imagination : it is his province severely to analyze, reckon up, and register results : this, and neither less nor more than this, is his duty. He must be actuated by the inflexibility of the just judge, who applies the law uninfluenced by passion or private feelings ; by the rigor of the statist, w'ho, in drawing up a table of mortality, pays no attention to causes of death, and confines himself to the computa- tion of the chances of life in an entire population." Finally, the numeri- cal method applies, in all its rigor, the calculation of probabilities to medi- cine. The inductive method is a totally different procedure: it collects and analyzes facts; but it likewise compares them, and does not always sum up their number. In place of the necessary result obtained from statistics, it seeks for something else, viz., the systematic relation and connection of facts: it interrogates facts, comments upon them, separates them, groups them, examines.them in every aspect, with a view to eliminate from them something new and applicable. In a word, in opposition to the numerical method, it puts as much of its own as it possibly can into its interpretation of facts, well assured that by so doing it will approach more nearly to the truth. The first part of the sentence of J. J. Rousseau, w hich I have just quoted, is nonsense. It is evident that facts, just because they are facts, are, of necessity, true: in this sense, to affirm their existence, points out what they are; and it is neither correct to say that facts are true nor that they are false, but simply that they are. The estimate of facts may be either true or false, but the estimate belongs to the mind of him who forms it, and in no degree whatever to the facts themselves : it is absurd, therefore, to say that " the truth is in the facts, and not in the mind which interprets them." The second part of the sentence has only a false appearance of truth: it is clear that if, in respect of two given facts, we confine our judgment to pointing out the immediate link by which they are united, we put into that judgment the least possible amount of our own, and that, if we have not given much of a judgment, we have at least given one which is suffi- ciently sound. Nevertheless, even in forming judgments upon the most general relationships of facts, it becomes necessary to put in something of our own, because judgments are mental acts, and are essentially outside the facts. The question, therefore, to be determined is, whether we ought to put into our judgments as much of our own as we can, or whether, as seems to be the wish of J. J. Rousseau, as little as possible of our own. For myself, I can give an unhesitating answer to this inquiry. The more we lay hold of and point out numerous ways in which facts are related to each other, the nearer do we get to the complete truth, and the less complete the truth is, the less truth does it contain. I do not reproach the numerical method because it numerates, but I reproach it because it only numerates: in a word, because it depends, like the mathematician, upon an absolutely exact result. I reproach it for counting too much, for counting too long, for counting always, and for declining to put any mind into the facts. This method is the scourge of in- tellect : it transforms the physician into a calculating machine, making him the passive slave of the figures which he has massed up: the greatest reproach which I cast upon it is that it stifles medical intellect. Those who 54 INTRODUCTION. admire the numerical method, applaud consequences which I deplore; they do not wish for the intervention of intellect; I do-I wish to see intel- lect exercising itself in all its power. I am anxious to make myself clearly understood; I employ statistics, I even employ, if you like, the numerical method, provided it be only regarded as a means sometimes preparatory, and most frequently comple- mentary ; but I spurn it with all my energy when it pretends to be a method complete in itself, and capable- of conducting us, as a matter of necessity, to the truth. The numerical method leads to results which are, and can be, nothing more than crude facts and elementary ideas. These facts and ideas are food for the intellect which elaborates them. This method, moreover, pre- sents but a very slight fundamental difference from that which has hitherto been universally employed. A practitioner of the past, who was studying measles, perceived, I presume, a primary fever, a rash, desquamation, and complications, of which he took account-he registered his observations, and then he noted which facts were general and common, and which were accidental and special. Practitioners, then, of past ages acted in no differ- ent way from that I have now described, and so likewise proceeded in our own time, before the numerical method was invented, Corvisart, Bayle, Laennec, Rostan, Lallemand, Andral, Bouillaud, Calmed, and many others. When they had examined in the closet the observations collected at the beds of their patients, they noted results, and then drew conclusions. What more does the numerical method do ? It calculates rigorously. In place of saying "one hundred" patients, it says "ninety-nine," or "one hundred and four" patients; in place of saying (as Bretonneau first said) " in putrid fever, intestinal perforations occur in the ulcerated Peyerian and Brunnerian glands, and are seen rather frequently," it says " intestinal perforations are observed so many times in a hundred cases in place of saying " softening generally accompanies cerebral hemorrhage," it says, for instance, " softening accompanies cerebral hemorrhage sixteen times in twenty." The common method said, and still says, lobular pneumonia is a very frequent complication of measles, while the numerical method will tell you the relative proportion of cases which are, and which are not, complicated in that manner. It is, then, you see, a method of proceeding which has the appearance of being more exact; but, in reality, it does not differ from the other jnethod. If you observe with attention, you will arrive at the same principal con- clusions by the inductive as by the numerical method. When I set myself to study hooping-cough, I quickly perceive that the fits of spasmodic cough almost always cease, or at least become much less frequent, when the patient has, than when he has not, had an accession of fever. I pointed out this observed fact in my clinical lectures before I employed arithmetic-by and by I made use of statistics, and then, in place of saying almost always, I said so many times in so many cases observed, which is just another way of saying almost always. Do not imagine, gentlemen, that there is any reality in this mathematical exactitude; it is only a relative precision, for it changes under the observa- tion of the same man, according to the year, the season, and the reigning medical constitution. Thus, it happens, that the same fact which was ob- served last year once in five times, occurs this year only once in ten times, and next year, perhaps, it will only happen once in twenty times: so that your law, your true truth (y erite vraie) neither is, nor can be, absolute. If the pathologist endeavors to formulate the facts which twenty partisans of the numerical method have given, each as the utmost expression of exact- WHAT IS CLINICAL MEDICINE? 55 ness, he is obliged either to strike an average which will not be a true aver- age to-morrow, or to return to those odious and detestable formulae which it is desired to banish from medical phraseology-sometimes, often, most fre- quently, generally. Of what use is this semblance of precision? When one of our colleagues showed the medical world the coincidence which exists between diseases of the heart and acute articular rheumatism, was that beautiful discovery re- ceived the less favorably because the discoverer said "very often" in place of "forty-four times in the hundred?" Was the influence of sulphate of quinine on miasmatic hypertrophy of the spleen less surely established when Bailly said "almost always," than if he had said "ninety times in a hundred ?" But it will be alleged that the numerical method allows us to verify the assertions of a physician. Do you think, gentlemen, that if one wished to make a false statement, it would be less easy to do so by the use of exact figures than by the employment of the " some/v'mes " and "almost" phrase- ology? Do you think that the impudent, lying physician, if such there be, could not concoct a numerical result as easily as a general assertion ? The one method would only give him the trouble of lying sooner than the other; it will oblige him to begin by fabricating historical details so that he may announce an exact result: while in the other case he will, with less labor and hypocrisy, lie only in the false conclusion which he puts forth. Thus it is that, although I concede to the numerical method, as now practiced, a very minute degree of importance as a means of study, I recom- mend its employment, because it accustoms the student of medicine to pay attention, and enables him to appreciate better certain details which, though they do not escape a trained and intelligent observer, might remain unper- ceived by one less familiar with the sick. The physician who popularized the numerical method at the same time introduced statistical analysis into the study of pathology, and the minute dissection of the facts observed sometimes led him to new information, not the less worthy of being known and recorded that it was of a collateral character. Rigorous analysis, then, is not useless, and although it presents the very grave inconvenience of crumbling facts (d'emietter les faits), to use the happy expression of M. Bretonneau, in such a way as to disfigure them completely, it nevertheless makes us acquainted with some subordinate truths which will, sooner or later, acquire a certain scientific value. If the application of statistics to medicine was not rated too high, if it were not considered as the very keystone of the arch of all science, and if it were simply regarded as a method of proceeding a little less imperfect than the majority of those hitherto adopted, I should only praise it and recommend it to you, because I really believe it to be useful; but there is so much noise made about such poor results, that I cannot conscientiously assist in deceiving young men by countenancing a charlatanic parade of exactitude and. truth. The statist desires too many facts; he is well aware that statistics are valuable only through multitude of facts, and he seeks everywhere for the means of increasing their number. There is nothing of this kind in the inductive method, of which I am now going to speak to you. Bacon's "forest of facts," taken literally, has no great value, and as the expression is understood nowadays, it has no value at all. Undoubtedly two facts justify a conclusion better than one fact, one hundred facts better than two facts, and a hundred facts better than a thousand; that is to say, one isolated fact does not convey its lesson. People say to you, Bring to- gether facts; do your best to collect cases in as complete a form as possible; collect them passively, without exercising your intellect upon them; so far 56 INTRODUCTION. from permitting thought, till you receive fresh orders, repress every mental impulse; be the accountant who marshals figures, and thinks nothing about results till he has added up all the columns. I also tell you to gather facts, and to do your best to collect cases in the comp]etest form possible ; but from the moment that you have got one fact, apply to it all the intelligence which you possess, seek its salient features, look at the points which are clear, allow yourselves to indulge in hypotheses, and, if necessary, go ahead; scrutinize every word in the phrase, strive to understand the un- known tongue, try to stammer it out, and do not delay speaking it till the hundred thousand words of the dictionary are graven on your memory. On the morrow, a new fact will be added to the first; this will suggest new points of comparison, all the more obvious to you, the better you have studied and understood the original fact. Then you will proceed to the verification of your hypotheses, bringing together some things and separat- ing others-for when two notions confront each other within one intelli- gent head, the mind must find out what they have in common, and what they possess foreign to each other. Proceeding thus, you will soon be in possession of the Baconian " forest of facts." In the course of your progress, a thousand ideas will germinate in your heads, a thousand hypotheses, a thousand systems, will be con- structed and destroyed. You will no longer be the slaves of facts; you will hold them enchained, ready, summoned to respond to your interroga- tions ; they will not thrust an idea upon you, but you will call upon them to verify your ideas; as the submissive slaves of intellect, they will have to obey you, but they will require you to have an understanding with them, and this is the point at which the numerical method and statistics inter- vene. It is better, said Gaubius, to stand still, than to walk on in darkness- " melius est sistere gradum, quam progredi per tenebras." But in what man- ner has the human mind progressed from the beginning of time ? I ask you, if it has not always proceeded to verify an hypothesis after the fashion of the daring navigator who, with prow to the west, trusts to unknown seas his genius, his glory, and the lives of himself and his adventurous com- rades? What ideas germinated in the head of Galileo before he discovered the movement of the pendulum ! and do you believe that he required to see a thousand candelabra oscillating under the dome of Pisa to enable him to create that splendid hypothesis which soon became part of the domain of science? Toricelli formed an hypothesis; he put mercury and water into tubes, and thus he discovered a law! Lavoisier weighed the peroxide of mercury, and thus was modern chemistry discovered! In one fact, the whole science was revealed to him. How many millions had seen the steam raise the lid of a tea-kettle. Watt saw it once. The fact was fecundated, and the man of genius who invented the steam-engine at once made himself and his country illustrious. The proposition of Gaubius, adopted by one of the most eminent practi- tioners of our day, is true, provided its application be restricted to the in- credible vagaries of minds unguided by a single fact. It is obvious that if we proceed without either premises or induction to create a system which, sooner or later, we shall be asked to submit to the test of experiment, we do what is useless and absurd; but the proposition of Gaubius ceases to be true, and it especially ceases to be scientific, if we possess any facts, how- ever few in number they may be, and however insufficient as materials for systematization, to guide our first steps amid the darkness. These facts bear a certain analogy to the thread of Theseus and the blind man's staff; and though, assuredly, if we have no other aid, we are walking in darkness WHAT IS CLINICAL MEDICINE? 57 and running towards the unknown, we are, nevertheless, not without a guide ; and even if we find the road shut up, we shall have well merited the grati- tude of our successors for showing them that the way was not open, and so sparing them laborious research in a wrong direction. But the oftener we accomplish something better than this, we put up signposts in unknown defiles. I maintain, then, that it is better to walk in darkness than to stand still, if by darkness you mean primary facts and mental processes which precede secondary facts. Why should God have given us minds unceasingly yearn- ing towards progress and always devouring the future ? Why has he given us intellects ever active, eager to compare, to form conclusions, to abstract, and to systematize, were it not that the intellectual faculties might be con- stantly at work with the primitive materials called facts ? And are not the products of this mental work, ideas, inductions, hypotheses, and systems, to be tested by the numerical method and statistics? I hear you ask me, Why begin with induction and systematization, if you have ultimately to come to a matter of accountancy with facts and of facts? It is very easy for you to say to me, Shut the eyes of your understanding; here is an. object which presents itself with color, form, weight, and density ; state its modalities, but I prohibit you from forming a concrete. Is it possi- ble for me to refuse an attribute to the subject, to disjoin violently what my mind has strongly united and combined ? Can I see, hear, and feel, with- out judging-judge without forming conclusions-form conclusions without systematizing? What is it you wish? Shall I make a repertorium of ideas ? Shall I bridle my understanding, and wait for the signal to start on my intellectual race? You say, " Off!" But, I ask, how am I to equip myself for the course ? Do you suppose that the rust of inactivity can be rubbed off at your word of command? You wish the pupil to see only crude facts, and to stifle his intellect: and when, by means of this dismal labor, his mind has been to some extent mutilated, you will ask him to show mental vigor, and will dare to hope for his manifesting prolific thought. We must allow the luxuriant intellect of youth to grow up in freedom. We must take care not to stop the flow of that generous sap which seeks to spread forth only in blossom and branches; so long as the vital juice is drawn from a soil fertile in clinical observation you need not fear that the growth will stretch too far. The members of the Faculty whose duty it is to guide pupils in their practical studies will moderate their impetuous ardor. They also have some accounts to settle with hypotheses; but they have attained an age which has whitened their hair and ripened their expe- rience, and, having become accomplished practitioners, they place at your service, for your instruction, their disappointments, their knowledge, and as much of that which constitutes individuality in their art as it is possible to transmit. What I have said regarding philosophical methods is only applicable to the science, and in no degree to the art of medicine. In point of fact, methods belong to the sciences ; in the arts they neither have, nor ought to have, any existence. Method and art reciprocally exclude each other. Every science touches art at some points-every art has its scientific side; the worst man of science is he who is never an artist, and the worst artist is he who is never a man of science. In early times, medicine was an art, which took its place at the side of poetry and painting; to-day, they try to make a science of it, placing it beside mathematics, astronomy, and physics. In my opinion, a science deals with concrete elements or calculable ab- stracts ; it implies the possibility of formulae, and excludes individuality: an art creates manifestations without having calculated their connection 58 INTRODUCTION. with causes, thus implying the impossibility of formulae and proclaiming the idea of individuality. A Newton would be the most stupid of mathematicians if he only occu- pied himself with the calculus; a painter is a painter, and nothing more than a painter. Scientific results are, we may say, stereotyped ; results are not scientific unless they are identical-that is the criterion. Artistic re- sults are essentially various and variable, and the more individuality there is in the artist the more is he an artist. In the sciences there are no schools; in the arts there are as many schools as there are great masters. In accordance with the definition which I have given of science, provided the inferences which I have drawn from that definition be correct, I shall be allowed to regard medicine as an art; and those, even, who most ardently desire to see it raised to the rank of a science will doubtless admit with me that, up to the present time, it is very little deserving of the honor which they wish to confer on it. It would, no doubt, be very desirable to see all physicians, in a given malady, calculating the causes, the issue, and the treatment, with mathematical precision ; it would be beautiful to see all persons intrusted with the sanitary regulations of communities making up annually an exact balance-sheet of their practice, and proudly submit- ting their inflexible results to the inflexible examination of a court of medical accountants. Unfortunately, such a consummation can never be; we shall always be called upon to lament the deplorable uncertainty of medicine, precisely for this reason, that if science necessarily has princi- ples, art (which even ignores itself, which often goes forward to its object through darkness) can at best only have processes very difficult of trans- mission. In medicine, do not confound art and science. All cannot be- come artists; but persons of the most ordinary intelligence can make ac- quisitions in science; it does not, hqwever, gentlemen, follow that science is useless, or, in the present day, an unnecessary part of the education of the greatest men of art. We are, therefore, entitled to exact from you evidence of the possession of scientific knowledge, because it is something which can be acquired, and which by industry is acquired by all, in greater or less proportion ; but we will never exact more than scientific knowledge, for the rest is a natural gift. Take care not to fancy that you are physicians as soon as you have mastered scientific facts ; they only afford to your understandings an oppor- tunity of bringing forth fruit, and of elevating you to the high position of a man of art. I still recollect the concluding years of my medical studentship. Like many others, I went to a celebrated amphitheatre to study operative medi- cine ; like many others, I was led away by the exactitude of the methods which directed the knife and the lithotome in so invariable a manner; like many others, I made a hobby of the most laborious surgical operations; and when we were drawn by curiosity and the desire for instruction to the Hotel Dieu or the Charite hospitals, where the masters of the surgical art were about to put in practice the precepts which we knew so well, we often, with sly satisfaction, detected that the knife was going astray between the rough surfaces of a refractory articulation, or was not held at a sufficient angle to avoid a vessel with certainty; and then we were not far from think- ing that our right places were not on the benches among the students. What did it matter, though the operator was the best surgeon Who ever amputated at the shoulder-joint, or whether operative medicine was an occupation more difficult than that of the carver! Assuredly, if we could collect and reanimate the ashes of Ambrose Pare, if we could here evoke WHAT IS CLINICAL MEDICINE? 59 the most illustrious surgeon of modern times, J. L. Petit, I much fear that these two great men would be found less brilliant operators than many young students proud of possessing so easy a talent! Gentlemen, most of you know more chemistry than Paracelsus, many of you more than Scheele and Priestley, some of you even more than our La- voisier. You know chemistry, but still you are not chemists ; and among those who now hear me, do you believe that there are many whom posterity will deem worthy of being placed beside the men whose glorious names I have just mentioned ? Thus it is, gentlemen, that there is a great difference between the man of science who reaps, and the man of art who produces. Do not, therefore, fancy yourselves physicians because you have acquired the habit of applying to the diagnosis of diseases the ingenious proceedings by which science has become enriched since the beginning of this century. The admirable diagnostic methods-auscultation and percussion-given by Laennec to the public for the general good, and of which no one is allowed to be ignorant, are in our hands what the telescope and the magnifying- glass are in the hands of the astronomer and the naturalist-instruments intermediary between external objects and the mind; but a magnifying- glass will no more make a Tournefort or a Galileo, than a stethoscope will make a Sydenham or a Torti. And moreover, gentlemen, it is undeniable that the increased means of investigation possessed in the present day, by multiplying elementary facts, or at all events by rendering them more exact, does not fit the mind for producing more prolific, more practical, or more reliable manifestations of art. How, then, does it happen that the mind becomes indolent in propor- tion to the increase of scientific notions, satisfied to receive and profit by, but caring little to elaborate or originate them ? Scientific processes assist art less than is supposed. Chemistry teaches you how to form colors; it has told you wherefore, and when, they do not blend ; it has taught you to fix them upon a canvas less liable to change and better prepared. An illustrious man of science has given you a knowledge of the modifications which shades of color produce upon each other; in a word, he has made a science of the harmony of colors. And yet, the blood still circulates under the palette of Rubens, textile fabrics still shine resplendent upon the can- vas of Van Dyck, and the Madonnas of Raphael retain all the divinity and sweetness of their beauty. Why, then, with so many ways of study, with so much valuable scientific knowledge at command, have our painters remained so far behind the less scientific masters who constitute the glory of the art ? Why, then, do not we, so rich in preparatory knowledge, so rich in means of diagnosis, produce such men as Baillie, Sydenham, Torti, and StoR? It certainly is not because nature has been more chary of her gifts to us; each century brings forth the same class of minds, and ages the most abjectly barbaric have probably given birth to men of as vigorous intellects as those which produced Pericles, Augustus, Leo X, and Louis XIV. How often in our intercourse with the young men who crowd our benches do we meet with intellects of the highest class, who only require a fitting opportunity and a favorable direction to produce fruit! But some of you who have shown exceptionally great talents, when you have acquired, by long study, perhaps, but without difficulty, a knowledge of the prepara- tory sciences (to which unfortunately so large a place is accorded in the medical curriculum), when in a few months you have equalled, or, it may be, surpassed your masters in the easy art of applying the senses and the various obtainable instruments to local diagnosis, becoming elated by a con- quest which has cost you so little, and strengthened in the good opinion of yourselves by persons who look on medicine as consisting only of the com- 60 INTRODUCTION. mon stock of knowledge, accustom your minds to no efforts of production, and sink down into a sort of moral inertia; while, on the other hand, we see that our predecessors, less rich than we are in available knowledge, ceaselessly labored to originate: poor they were, but they turned to account the tiny stock of information which chance or experience had given them; they exercised their intellectual powers as constantly as wrestlers exercise their muscles, and the result was power, which sometimes showed itself in singular aberrations, but likewise also in views full of greatness and fer- tility. The very poverty of means increased the intellectual efforts, and the results were immense; and you, surrounded by a profusion of means, spoiled, enervated, cloyed with the abundance presented to you, know only how to receive and gorge, while your lazy intellects are smothered with obesity, and are sterile. For mercy's sake, gentlemen, let us have a little less science, and a little more art! But I said that a man is born the artist, and that he becomes the savant; I said that scientific knowledge is easy: well! already I hear persons who either understand me amiss, or think they ought to do so, accuse me of encouraging young men in apathy and fatalism. If, say they, we are born artists, we are likewise born physicians; let us quietly wait for the natural inspirations of art. I do not allow any one so to misinterpret my words. A man is born an artist in this sense-that if nature has refused you artistic aptitude, do what you like, you will never be savants; but, with the most happy aptitudes, you will be nothing without hard work. Hard work is a powerful source of inspiration ; contemplation of the masterpieces of art constitutes the educa- tion of the artist, and a painter, endowed with the loftiest intelligence, who would not go to pass some years of his life in that atmosphere of genius which is breathed on the other side of the Alps, will never be more than an incomplete man, shut up in his own straitened individuality, whereas with study, with example, he will at once profit by the laborious inventions of artists of past ages now belonging to and easily obtained from science, he will correct the flights of his impetuous imagination, which will be con- stantly brought back to the beautiful by the contemplation of the beauti- ful ; he will instinctively, involuntarily purify his taste, and all his origin- ality, henceforth properly directed, will throw itself in full force with the greatest ease into the lofty regions of art, and bring forth those wonderful productions which the artist bequeaths to the admiration of future genera- tions. God made Lavoisier, but our immortal chemist would not have been more than a happy farmer of taxes if he had not, amid the fumes of the furnace, and by frequenting the society of the scientific men of his day, educated that intellect which was destined to give birth to the most pro- lific of chemical discoveries. Do you suppose that Pare, J. L. Petit, Sabatier, and Dupuytren-do you suppose that Baillou, Fernel, Laennec, and Corvisart-do you suppose that Lavoisier, Fourcroy, Berthollet, and Dumas-do you suppose that they, and many others whose names are in the mouth of every one of you, could by the powerful gifts which nature bestowed on them have become princes of their art unless they had cultivated their natural powers at an early stage of their career, unless they had in early life greedily devoured the treasures of science which were spread out around them as they are spread out around you-unless, though wearied by, they had never been satiated with labor, and had believed that they had no right to reserve for their own use the riches which they had acquired, the discoveries by which WHAT IS CLINICAL MEDICINE? 61 they made themselves illustrious, and had been jealous to see their country, already foremost in literary renown, become foremost also in scientific glory ? May this, gentlemen, be your noble heritage. .But to secure it toilsome exertions are required. Whilst you are young, and while you make your first essay in arms, let your fields be the hospitals and the clinics; when your knowledge has increased, let the hospitals and clinics still be your fields; and let the hospitals and clinics continue to be your fields of industry after you have acquired all the scientific knowledge which we exact from you at the probationary examinations. By pursuing this plan, you will attain expertness in the practice of your art, knowing what science teaches, and having the power within yourselves of originating ; then, also, will you begin that priesthood which will honor you, and to which you will do honor; then, too, will commence the life of sacrifice, in which your days and nightswill be the patrimony of your patients. You must resign your- selves to sow in devotion that which you must often reap in ingratitude; you must renounce the sweet pleasures of the family, and that repose so grateful after the fatigue of laborious occupations; you must know how to confront loathsomeness, mortifications of spirit, and dangers; you must not retreat before the menaces of death, for death achieved amid the perils of your profession will cause your names to be pronounced with respect. LECTURES ON CLINICAL MEDICINE. LECTURE I. SMALL-POX. Gentlemen : Since the great discovery of Jenner, small-pox seems to have occupied a much less important place in medicine. It was even hoped in the early days of vaccination that a means had been found to destroy the worst scourge which ever decimated the human race; but ere twenty-five or thirty years had passed away, in spite of the practice of vaccination, epi- demics of small-pox reappeared, and did not always spare the vaccinated. In giving the history of cow-pox, I propose to tell how it has lost some of its original properties, to study the plan by which it may, perhaps, be pos- sible to restore to the vaccine virus that which it has lost, and likewise to state the methods by which vaccination may henceforth be made as effica- cious as possible. Cases of small-pox are at present so common that a week does not pass without our seeing patients afflicted with this disease in our wards; whereas, thirty years ago, in the same wards, they were exceedingly rare, and only met with in persons who had not been vaccinated. Is not one entitled to ask, whether this change does not depend upon the medical constitution through which we have been passing for a certain number of years, and which might have been otherwise more troublesome had it not been ren- dered milder by cow-pox ? Although epidemics of small-pox do not spare even those who have been vaccinated, it must be owned that they spare most of them; again, in most of the vaccinated, the disease has generally been modified in its form and symptoms, so that vaccination, though it has not in our day its original efficacy, still retains a degree of efficacy which cannot be disputed. Nevertheless, although antecedent vaccination generally modifies the disease, small-pox is a terrible calamity when it scourges even vaccinated communities, but it is the most severe of all epidemic diseases when it at- tacks the unvaccinated. Perhaps some of you have read the account of the epidemic of small-pox which ravaged the aboriginal Indian tribes of Canada some years ago; nearly twenty-two thousand persons were attacked, and in from five to six months almost the entire population was carried off by this frightful fever. At the close of last century, in proportion as the naviga- 64 SMALL-POX. tors penetrated into the isles of the Pacific Ocean, small-pox, which the men of the old continent brought with them, burst forth with fury among the inhabitants of the newly-discovered world, and the mortality assumed a frightful magnitude. It appears, then, that the study of small-pox is a matter of great impor- tance, and this importance will probably increase more and more in conse- quence of the neglect of the practice of revaccination, which, though as commendable as it ever was, is rejected by many physicians, and is not universally accepted by the public. For fifty years the study of small-pox had come to be looked on as of secondary importance in medical education. It has now become necessary to return to it and insist upon it; I also propose, therefore, to sketch the principal features of the disease. Though I have acquired a sad experience in small-pox, I have learned almost nothing regarding it which has not been much better observed and described before me. I shall, therefore, take Sydenham as my guide. Some of you have in your hands extracts from his writings, which I have arranged in the form of aphorisms in a pamphlet of a few pages, containing the most important statements made on this subject by the English Hippocrates. I now propose to paraphrase this little book, and to add to it some critical remarks; I will sometimes appeal from the writings of Sydenham to the clinical studies which we pursue together in the hospital, and, without changing much of what that illustrious man has said, I hope to teach you everything which it is essential to know regarding this exanthematous pyrexia. Small-pox differs from scarlatina in this respect, that it always shows itself to the eye. During the first few days, during the period of invasion, one may not have suspected it, but as soon as the eruption appears there is no longer any scope for hesitation. Its manifestations are unmistakably characteristic, and it ought not to be possible to confound variola even with varicella, an essentially different disease, though the two are sometimes confounded with each other. Small-pox is subject to modification in respect of the eruption, and the course which the disease runs. This modification, or new phase, is the consequence of antecedent small-pox or cow-pox. It is an error, as I shall afterwards explain, to apply the term varioloid to modified small-pox. Under all circumstances, whether modified or unmodified, small-pox ap- pears under two principal forms, viz., the distinct and confluent; and whichever form it assumes, the symptoms are either normal or abnormal. It is not a matter of indifference to establish the varieties of the disease, and it is quite essential to recognize its two principal forms; for distinct small-pox is generally free from danger, while confluent small-pox is one of the most terrible of diseases, almost always proving fatal to those whom it attacks. The course and termination of the two are so different, and the phenomena which characterize them so decisively distinctive, that it is of the utmost importance, following Sydenham's example, to describe and study each separately. Distinct Small-pox. - Constipation.-Convulsions. - Rachialgia.- Para- plegia of Small-pox.-Duration of the Period of Invasion.-Eruption considered with reference to its position on the Face, Trunk, and Limbs. - Orchitis of Small-pox.-Desiccation. In every case of small-pox, the clinical observer can recognize a period of incubation, and four other periods, viz., those of invasion, eruption, maturation (or suppuration), and desiccation. DISTINCT SMALL-POX. 65 The period of incubation has a duration the extent of which has been es- tablished by observation in eases of ordinary contagion, and demonstrated by experiment for more than half a century in Europe, by the inoculation of natural small-pox. Attentive observers, then, have satisfied themselves in a precise manner as to the number of days which elapse between inocu- lation and the manifestation of the disease; they have ascertained that, except in extraordinary and exceptional cases, the period of incubation ex- tends to between eight and eleven days. The period of invasion, in distinct small-pox, is characterized by a violent rigor, or sometimes by many rigors, interrupted by accessions of burning heat; and these phenomena are always more decided , in this disease than in any of the other exanthematous pyrex he. The skin continues relaxed up to the eighth day, and, in the adult, sweating is an essential symptom; in children it is otherwise. The perspiration, which appears with the first access of fever, is checked by nothing, and continues, even when the patients are lightly covered, up to the period of maturation ; it then goes on, even when the fever has subsided, and after the completion of the eruptive process; it seems to constitute a favorable crisis on the part of the skin, coming in aid, as a sort of emunctory discharge, to the great cutane- ous eruptive manifestation. I must here remark, that in confluent small- pox this tendency to diaphoresis is generally absent. In distinct small-pox, the period of invasion is also characterized by vomiting, or a desire to vomit; this symptom is very seldom absent. A more important symptom, still more rarely wanting in adults, is constipa- tion ; it persists during the entire course of the disease, or at least the bowels are relieved with difficulty. It must be mentioned, however, that in some epidemics diarrhoea has been observed in adults.* Diarrhoea in children, on the other hand, is the rule and not the excep- tion. Besides this complication, there are others met with in children, to which it is still more important to call attention. In the first place, there is a tendency to sleep; and still more frequently, even in those who have cut their teeth, convulsions occur. They more frequently occur in children in the earliest stage of small-pox than at the corresponding epoch in cases of measles or scarlatina. So well aware was Sydenham of the frequency of this symptom, that when he met with convulsions in a child whose den- tition was completed, he at once suspected that he had to do with a case of incipient small-pox; he did not consider convulsions ushering in an attack of small-pox as at all a serious complication. This proposition, however, if applied generally, requires to be stated in a less absolute form; if a child, for example, has one or two convulsive seizures shortly before the appearance of the eruption, it is not in great danger, but there is more risk when the convulsions occur early and recur frequently. For my own part, however-but my experience of small-pox in children has been small-I should say that the occurrence of convulsions is a troublesome complication rather than a favorable symptom. It must be borne in mind, too, that (as Borsieri has remarked) convulsions may constitute a misleading as well as a serious symptom, inasmuch as they sometimes carry off the patients be- fore the appearance of the eruption. * Diarrhoea in the adult.-"In quadam constitutione epidemica variolas obser- vavit Carolus Richa, quae cum alvi fluxu incipiebant, et eundem ad finem usque comitem habebant, bono cum eventu, sive id a saburra primarum complicata eveniret, sive a materiae variolosae portione, quae hac via excerneretur. (Conail. epid. Taurin., anno 1720, g xv).-Vogelius, etiam, diarrhceam salutarem ab initio ad un- decimum usque diem vidit, lethalem vero earn quae postea supervenerit."-Note of Borsieri, p. 150. VOL. I.-5 66 DISTINCT SMALL-POX. Simultaneously with the shivering and sweating, the burning fever and the vomiting, another important symptom supervenes-this is pain in the lumbar region-(rachialgia?)-it is hardly ever absent, and in no other pyrexia, excepting yellow fever, is it so severe. It is not, as has been sup- posed, a muscular pain, but is dependent upon an affection of the spinal marrow. Here is the proof. In a great many cases (and last year within a few days I could have shown you two examples) the lumbar pain is ac- companied by paraplegia. Without your putting any leading questions, the patients themselves mention this paralysis; they complain of painful numbness in, and inability to move, the lower extremities. When you in- quire whether the upper extremities are similarly affected, you discover that their motor power is in no degree impaired. The paralysis sometimes affects the bladder, as is evidenced by retention of urine,, or at least by great dysuria. The paralytic symptoms are generally of short duration, but in some cases they continue till the ninth or tenth day; generally, they cease spontaneously when the eruption appears. There are, however, some cases in which the paralysis persists not only during the whole course of the disease, but likewise constitutes one of the complications of conva- lescence. When the lumbar pains are not very acute, the patient only experiences lassitude and dull pains (like those of rheumatism) in all the limbs, with occasionally pain, increased by pressure at the pit of the stomach. "Doloris sensus in partibus qua scrobiculo cordis subjacent, si manu premantur" says Sydenham. To sum up: the period of invasion is characterized by rigors, ardent fever, and constant sweating, by nausea and constipation, by disturbance of the nervous system, such as convulsions in children ; by general, but particularly by lumbar pains, with which are frequently associated paral- ysis of the inferior extremities, and occasionally paralysis of the bladder. I must, nevertheless, remark that in some exceedingly rare cases men- tioned by old authors, small-pox proved so mild that the eruption made its appearance without having been preceded by any febrile disturbance ; the outbreak of the pustules was either the sole manifestation of the dis- ease, or if there was any fever, it was so slight as to have passed unnoticed. In such cases, as Borsieri has remarked, there is no appreciable period of invasion. In distinct small-pox the period of invasion is usually three complete days; rarely three days and a half; still more rarely four days; and almost never only two days. This duration is so generally the rule, that when one sees, after the inoculation of natural small-pox, the fever of in- vasion set in with a certain amount of vehemence, and three times twenty- four hours elapse before the eruption is developed, it may be prognosticated with certainty that the attack will not be severe. The fact is, that the longer the eruption is in appearing, the less serious will the disease prove; and the less delay there is in its appearance, the more dangerous will the disease prove. When the eruption appears at the end of the second day, it is cer- tain to be confluent; if on the third, it is almost always confluent. If, on the other hand, the eruption does not appear till the fourth day, still more, if it be delayed till the fifth or sixth (as in a case observed by Violante), or till the fourteenth (as in a young girl whose case is recorded by Haen), it is necessarily distinct. Sydenham, nevertheless, informs us that in some exceptional cases in consequence of great organic lesions, ob atrocius aliquod symptoma, the eruption may be retarded till the sixth or seventh day both in distinct and DISTINCT SMALL-POX. 67 confluent cases. But under such circumstances, there exist, in addition to the ordinary symptoms of the period of invasion, others depending upon the profound disturbance of the economy and the danger which lies con- cealed in the affection of an internal organ. In support of the observation of Sydenham, let us recall the circumstances of a case which we had in 1862 in the St. Bernard Ward, bed 27. The patient was a woman of 30, in whom the eruption did not appear till the fifth day; at the commence- ment of her attack of small-pox, she had had all the symptoms of sporadic cholera, such as vomiting, purging, cramps, general coldness, blanching of the mucous membranes, dry cold tongue, injection of the conjunctiva, and a dull appearance of the cornea. The choleraic symptoms ceased on the fourth day, and on the fifth the eruption of small-pox appeared. At the commencement of the second period, that is, as soon as the erup- tion appears, the fever subsides, and the other symptoms cease, except, as has already been stated, the tendency to perspire, which continues till the maturation of the pustules. Recollect that I am now speaking exclusively of distinct small-pox; in the confluent form the symptoms in question do not cease with the appearance of the eruption. I ought here to remark that modern scientific precision has confirmed the observation of the old clinical observers. The thermometrical researches of Wunderlich and his scientific emulators show that when the eruption appears, and when the pulse is found to diminish in frequency, the other phenomena characteristic of fever disappear; there is simultaneously a notable fall in the general temperature, which gradually returns to its normal standard, which, as you know, is 37 degrees in the axilla. Here are the leading facts in relation to the progressive change of tem- perature in the distinct form: At the commencement of the disease the temperature rises very quickly, and remains as high for a considerable time as from 40° 5" to 41° 5", that is to say, that the temperature of the body rises from three to four and a half degrees above the temperature in health, which is an enormous increase. From the time of the appearance of the eruption the fall of temperature is so rapid that in about thirty-six hours it has gone down to below thirty-eight, or, in other words, has become normal. This diminution, though gradual, is not continuous, for while there is a fall of one degree in the morning, there is a rise of half a degree in the evening. It appears, however, that from the time of the disease becoming external, so to speak, the central temperature falls, and there is a complete remission in the general symptoms. The Germans apply the term defervescence to the return of the body to its natural temperature. We shall afterwards attend to the thermometrical phenomena which are seen when every pustule has become a centre of suppuration. I now return to the description of the eruption. • The Eruption.-The eruption first shows itself on the face and neck; but, according to Swieten and Borsieri* it appears also at the same time upon the scalp, a fact which can be most easily verified in persons who are bald; it then comes out a little upon the upper part of the chest; soon afterwards it takes possession of the arms and hands, and later of the trunk, that is, of the lower part of the chest and of the abdomen, in which latter situ- ation the pustules are very few in number, and sometimes altogether want- ing ; last of all, the eruption invades the legs. The successive order in the appearance of the pustules is not so regular as authors describe it to be. If the eruption appears to commence on the face, it is because it is best seen there. When I have uncovered patients, I have seldom found pustules on the face without finding them in quite as advanced a state on the trunk and limbs. From the commencement, also, 68 DISTINCT SMALL-POX. of the eruptive period, the patients complain of pain in the throat, which depends upon the existence of pustules on the mucous membrane of the pharynx and mouth. In very rare cases, some of which have been described by authors, and some of which I have seen, the only symptoms characteristic of the disease were a few pustules on the pharynx and pendulous veil of the palate. The skin, to which one naturally ought first to look, is, at the commence- ment, studded with spots resembling exceedingly fine pricks made with a needle, and still more with papulse, such as are met with in persons affected by lichen or prurigo; these small specks, which are red, slightly pointed, and hardly above the surface of the skin, are disseminated over the face, neck, and upper part of the chest. Next day they are more prominent, and from the sixth day of the disease, which is the third of the eruption, the vesicular papules begin to contain a milk-like fluid ; next day they increase very perceptibly, their elevation is great, and the fluid which they contain becomes a little more opaque. On the eighth day they have become much larger still, and their opacity is also more decided. After the eighth day, it is very important to consider small-pox in rela- tion to the eruption as seen on the different parts of the body, because it takes very different forms, according to the parts affected. On examining the face, neck, trunk, and upper part of the limbs, we perceive a sort of gradation, which enables us, however, to recognize the eruption as essen- tially the same in these various situations: nevertheless, on comparing the papules on the hands with those on the face, the differences between the appearances of the two strike one as being considerable. On the face, as I have already said, the eruption, on the first day it is visible, presents the appearance of small, red, slightly acuminated papules, which next day become more elevated, and on the third day (which is the sixth of the disease) are filled with an opaque, but as yet non-purulent fluid. They go on increasing in size: they generally vary in size, and do not all resemble one another: some are small and some are large, but none attain a magnitude equal to that seen on other parts of the body; and whatever be their size, they all pass through the same stages. On the seventh day of the disease, they still further augment in volume; and upon the circumference of the base of each papule a redness begins to be per- ceptible. On the eighth day, this coloration becomes bright, and the more bright and rosy it is, so much the more may the disease be regarded as normal. The eruption now consists of small abscesses-of pustules; the pustules become painful, and swelling begins. This is the starting-point of the third period-the' period of maturation and suppuration. The swelling attains its maximum on the following day, that is, on the ninth day of the disease; it decreases on the tenth, and by the eleventh day has disappeared. The tumefaction, which is always great in propor- tion to the abundance of the eruption, is apparently, but not really greater, in the distinct than in the confluent form; it is specially conspicuous in certain situations, particularly upon the eyelids, which swell out in a re- markable manner, from the laxity of their cellular tissue. When even there are only three or four pustules upon the eyelids, they become so swollen, that Sydenham compared them to puffed-out bladders-vesicant inflatam non male refert; and on the ninth and tenth days they prevent the patient from opening his eyes. It sometimes happens, as in a case which we saw in the clinical wards, that pustules occur on the ocular conjunctiva. The swelling is sometimes quite as conspicuous in other regions as on the eyelids. Van Swieten, for example, saw a single pustule on the prepuce of a child produce a phimosis, which occasioned difficulty in passing the DISTINCT SMALL-POX. 69 urine. And here, gentlemen, let me recall the fact to your recollection, that the cellular tissue of the prepuce is of exactly the same nature as that of the eyelids. In confluent small-pox, to which we shall afterwards return, the swelling of the face being more general, the tumefaction of the eyelids has the appearance of being less than it really is, and less than in that form of the disease which we are now studying. At the beginning of the period of maturation, the progress of the pus- tules on the face is special. Up to the eighth day, they are velvety and soft to the touch-leves ad tactum, to use Sydenham's expression ; but after that day, upon passing the hand over the nose and cheeks, they are felt to be rough-asperiorus, ad tactum rudiores; and this roughness depends upon a slight oozing from the surface of the pustule of a yellowish matter like thick honey. This exudation only takes place from the pustules on the face, where they dry up immediately, the desiccation being complete on the eleventh day. The pustules on the trunk and extremities have a more regular form, and present more similarity to each other; while those on the face are not navel-shaped, those on the body begin to flatten on the eighth day, and sometimes to exhibit in their centres a small grayish depression called the umbilication. It must not, however, be supposed that the formation of this umbilication is a necessary occurrence. Upon the arm of patients affected with true small-pox, I lately circumscribed a certain number of pustules, and it was found that in only two or three of them did umbilication occur. Do not suppose, then, that the undergoing this change of form is a special character of the small-pox pustule; you will find this very same: umbilica- tion occurring in the simple pustules of ecthyma, particularly in the ecthyma produced by friction with tartar emetic. And let me here remark, as a circumstance noteworthy in connection with this point, though not otherwise of any importance, that some physicians of the last century re- garded it as an inauspicious sign when pustules were observed, which, though somewhat prominent, were not acuminated, but, on the contrary, bore a small central depression-in apice faveolam impressam gerunt. About the eleventh day, the pustules are filled with a purulent fluid: from that time may be noticed upon the upper part of the limbs, and particularly on the knees and elbows, a drying up of some of the smallest, but without any exudation similar to that seen to proceed from face pus- tules : between the fourteenth and seventeenth days, as a general rule, desiccation is completed. On the hands, the appearances presented are different from those hitherto described. From the eighth to the eleventh day, the pustules resemble those on the body, if it be not that the inflammation of the base commences later; but towards the close of the ninth day, the hands continue to be a little painful; on the tenth they swell, and concurrently with the tumefac- tion of the hands, oedematous swelling of the forearm is observed, which extends to the elbow, and is very painful. This condition is seldom of equal intensity on both sides, a fact which I am unable to explain. Per- haps it may depend upon the crop of pustules being a little more decided on one side than on the other, or upon the patient resting more on one side, and the swelling being greatest where the impediment to the venous circu- lation is greatest. If the eruption has been, I do not say confluent, but somewhat abundant, the patient is unable to close his hands from the tumefaction of the skin. The existence of this oedemato-phlegmonous swell- ing is shown in a very simple manner. It is sufficient to press more or less gently upon the skin between the pustules to leave the mark of the finger; this swelling and pain, which never set in before the eleventh, continue till 70 DISTINCT SMALL-POX. the fourteenth day. Similar phenomena occur in the feet, as in the hands, when the eruption is copious upon them. While the pustules have generally acquired their greatest size upon the trunk about the eleventh day of the disease, they continue to increase in volume till about the fourteenth day upon the hands, feet, forearms, and lower part of the legs ; the oedemato-phlegmonous swelling by which they are surrounded then goes down, leaving them without umbilication, and presenting the exact appearance of beautiful, perfectly round drops of vir- gin wax. They are, in fact, thickish phlyctseme filled with pus. Generally speaking the pustules of the trunk and limbs burst instead of desiccating-disruptione abitum sibi parant; the pus which they contain escapes, and soils the sheets and body-linen of the patient. The rupture takes place in three or four days; but on the hands, feet, forearms, and lower part of the legs, they remain unbroken until the eighteenth, nine- teenth, twentieth, or even twenty-second day, an example of which latter occurrence I had an opportunity of showing you. Sydenham, then, was mistaken when he wrote that their duration is not more than one or two days longer than that of the pustules on the body-diet unius aut alterius mora illas vincunt. I have, however, gentlemen, pointed out to you at the bed of the patient, that if the pustules on the back of the hand and on the forearm present the characteristics with which I have just made you ac- quainted as occurring on the dorsal aspect of the fingers and toes, they cornify and desiccate without suppuration, exactly like the pustules of modified small-pox, or like those of the knees and elbows of the unmodified disease. Before leaving this subject I must remark that it is in the most vascular parts of the skin that the eruption is most copious ; and, as was pointed out long ago by observers, the situations in which the pustules are most numer- ous are the face, the extremities, the circumference of small wounds (such, for example, as those made by the cautery), or the vicinity of blisters. Let me recall to your recollection, as a case in point, the patient who occupied bed No. 9 of St. Agnes's Ward, a lad in whom the eruption was very abun- dant on the posterior aspect of the forearms; he was a cook, and in that capacity constantly had these parts exposed to the heat of kitchen-stoves. At the commencement of the period of maturation or suppuration, there is a new manifestation, viz., the fever of maturation. The serious symptoms present at the beginning of the disease had so entirely disappeared with the coming out of the eruption, that the patient had regained his cheerfulness and appetite ; but they return on the eighth day, and constitute the fever of maturation. Here, again, investigation with the aid of the thermometer gives valuable information. We have seen that on the fourth day of the disease, at the date of the appearance of the eruption, and also whilst it continues, there is a fall in the temperature of the body and a truce to the fever, the entire morbid effort being concentrated, so to speak, in the skin, but the tempera- ture does not remain for more than a day or two, or for three days at the most, at the normal standard of 37° ; it rises a little during the period of suppuration, but does not become so high as it was during the initial fever. In severe cases, however, the fever which attends suppuration is more in- tense, and the temperature may even rise as high as it was before the erup- tion appeared. T6 be more precise-in slight cases, within three days, the temperature rises to about 38.5°, while in the more severe cases it may rapidly ascend to 40.6°, and even to 41.2°. This great elevation of tem- perature, however, is most frequently observed in the confluent form of the disease, of which I shall immediately have to speak to you. In the mean- DISTINCT SMALL-POX. 71 time, to sum up what has now been stated, I may say that the central tem- perature rises anew about the seventh or eighth day of the disease. The fever of maturation lasts for three days; on and after the eleventh day of the disease the patient is free from it, provided the case is of the distinct form. The temperature becomes again the exact index of the progress of the fever ; thus, after having risen to at least 38.7° in the fever of maturation, it falls progressively in three days to the normal standard. If the fever continue longer, it depends on complications, which, as I have already said, are rare in the distinct form of the disease. Orchitis, and ovaritis, its analogue in the female, next claim our attention as phenomena which sometimes occur concurrently with the appearance of the eruption. M. Beraud, an hospital surgeon, has in recent years treated the subject in a very complete manner.* We must not restrict the terms orchitis and ovaritis to inflammation of the parenchyma of the testicle or ovary, but extend it to inflammation of the tunica vaginalis, and the folds of peritoneum which surround the ovaries. The inflammation of the serous membrane is the result of the small-pox eruption affecting them as it does the skin, although of course the appearances presented in the two-situations have very different characters, just as herpes on a mucous surface is very different from herpes on the skin. Small-pox manifests itself upon other serous membranes than those now named. Long ago, Van Swieten and Hoffmann had called attention to variolous meningitis; Fernel, Werlhoff, and Violante have mentioned variolous affections of the lungs and intestines twenty-seven years ago; Pedzholdt published the observations he made on variolous meningitis and peritonitis, in the epidemic which prevailed at Leipsic during the winter of 1832 and 1833. Variolous orchitis is detected by the patient complaining of pain when the slightest pressure is made on the scrotum, or when he moves; forthwith, swelling of the parts is perceived, and subsequently fluctuation ; the pain is less acute when the inflammation occupies the parenchyma of the organ. The symptoms of ovaritis are not so well marked, and are less known. The facts recorded by Bdraud have been regarded as exceptional. Till he wrote, neither my attention nor the attention of any one had been specially fixed upon this subject; but his work had scarcely been published when, within a week, I showed you two cases of variolous orchitis in my wards. Since that time, we have had similar cases, not because they are more common now than in Sydenham's time, but because we now look out for the affection, and have learned how to detect its presence. In the same category we must include diphtheritic paralysis and rheumatismal disease of the heart, affections which, though not more common,have recently been better observed. From all I have now said, gentlemen, respecting the rise and fall of the temperature of the body in small-pox, it follows that the thermal line drawn for this disease is a material and striking representation of the singular course of the fever. Indeed, there is nothing more characteristic than the curve in the line which indicates the rise and. fall of temperature in small- pox. There is, first of all, the rapid rise at the beginning of the attack, then the continuance of the high temperature for two or three days, that is during the initial fever; secondly, there is a gradual diminution in heat during the two days which correspond to the period of eruption ; thirdly, a fresh rise' of temperature (more moderate than is seen at the beginning), correspond- ing to the fever of suppuration ; while fourthly and lastly, the diagram in- * Beraud: Archives Generales de Medecine, Mars et Mai, 1859. 72 DISTINCT SMALL-POX. dicates a return to the normal temperature, marking the period of desicca- tion to have been reached. Period of Desiccation.-Let us now study this fourth period, and consider how cicatrization is accomplished. Upon the face and body, crusts are formed, which fall off; upon the hands, the abraded epidermis leaves in its place a small red surface, ex- actly like that left by the pustule of ecthyma. Upon the fall of the crusts -which takes place from the face pustules about the fifteenth, eighteenth, or twentieth day, and a little later from the body-pustules-there remains in their stead, not a depression, but a projection of a violet-red hue, deep in shade as in the skin of individuals who have been exposed to cold. On this projection a small scale of epidermis forms, which separates in a few days, and is succeeded by a thinner scale, which in turn gives place to another thinner still, and thus, in succession, epidermic scales form and fall during a period of from ten to thirty days. By degrees the projection diminishes; after from four to six weeks there is seen in its place a slight depression; in four, five, or six months, the redness of the skin has disap- peared, leaving only the small whitish puckered cicatrix familiar to all of you. It must, however, be recollected that when the disease has been of the distinct form, and when the pustules on the face have not been very large, the red marks generally disappear without leaving more than a slight and transitory unevenness of surface; but there are other cases in which, notwithstanding the absolutely "distinct" character of the pus- tules, deep cicatrices are left. Such is the normal course of the distinct form of small-pox ; it is not a fatal disease. Distinct small-pox, however, though apparently strictly normal, may sometimes, though very rarely, terminate in a manner totally unlooked for, as so often happens in scarlatina. Recall to your recollection a young woman of twenty-one who lay in bed No. 7 of St. Bernard's Ward. She had passed through a remarkably mild attack of distinct small-pox. The sister of the ward had left her at eight o'clock in the evening in a perfectly satisfactory state. Soon afterwards she was seized with cerebral symptoms, and difficulty in breathing ; in an hour she was dead. It is a curious, anomalous fact, that when distinct small-pox does prove fatal, death occurs earlier than in the confluent. Sydenham observed, and so have I in many cases, that when death occurs in distinct small-pox, it happens about the eighth or ninth day, but not till the eleventh or thirteenth in the con- fluent. The illustrious physician whom I have just named, Sydenham, and after him Van Swieten and Borsieri, observed anomalous and malignant epi- demics of distinct small-pox. They were characterized in the prodromous period by the severity of the pain in the head and back, great prostration of strength, anxiety, agitation, stupor, and sometimes by delirium. The want of appetite, amounting to disgust for every kind of food, was very marked. Sometimes there was delirium and sleeplessness; at other times, profound coma, twitchings of the tendons, a tendency to syncope, and very often, irregular, quick, and laborious breathing-the latter, an indication of great danger. The fever was at times very high, and at other times the pulse was small, feeble, and irregular ; there was not much heat of skin ; the perspiration was very copious. The eruption came out well on the third or fourth day, but there was more than one crop : on the fifth or sixth day fresh pimples appeared ; all the pustules did not attain the same size, some remaining pale and indolent, while in cases where the eruption was mild, pressure on a level with the pustules occasioned acute pain. CONFLUENT SMALL-POX. 73 The fever and other disturbances of the system continued, in place of sub- siding on the appearance of the eruption, as in ordinary cases. Inordinate perspiration stopped suddenly, and could not be recalled in any degree by treatment. Micturition was frequent, but scanty, and sometimes there was suppression of urine, a symptom which Sydenham regarded as of most unfavorable augury at that stage of the disease, as well as in the decline of the distinct form. Occasionally, copious diarrhoea set in. At last, the patient sunk, as I have already said, on the eighth or ninth day, under the nervous and comatose symptoms of which I have spoken. From the facts now stated, it appears that when the eruption does not come well out by the fifth, sixth, or seventh day-when the pustules are irregularly developed ; when the perspiration ceases, and cannot be restored; and, lastly, when delirium, profound coma, and twitching of the tendons continue or supervene, the worst possible prognosis must be formed. The fatal issue is impending and very near. Delirium, however, must not be confounded with acute mania, of which we had a case in a woman, who, during the progress of modified small-pox, presented no disturbance of the nervous system, except attacks of mania without fever. At the beginning of the fever of maturation, on the sixth or seventh day of the disease, it is not unusual, even in distinct small-pox, to meet with delirium, lasting for one or two days ; it is most frequently observed at night; sometimes it is rather violent. At one time I used to be mu'ch alarmed by the occurrence of delirium; but at present it is a symptom which gives me no anxiety. It subsides without the intervention of art, and modifies neither the general character nor the prognosis in distinct small-pox. Here I must, however, make certain reservations. I do not fear delirium if the pulse maintain its volume and do not become rapid, if sweating continues ; but if the skin is dry and cold-if the pulse lose its proper strength and become small, sharp, or irregular, the delirium has a very different meaning, and is a certain sign of approaching death. Confluent Small-pox.-Diarrhoea, (chiefly in children) at the commence- ment of the illness.-'Salivation.-Swelling of the Face.-Swelling of the Hands and Nervous Complications.-Boils.-Abscesses.-Purulent Infec- tion.-Albuminuria.-A nasarca.- Treatment. When the fever of invasion is exceedingly intense-when the initial shivering has been greatly prolonged, the pain in the loins acute, the paralysis of the lower extremities and bladder very decided, the vomiting continuous-when sometimes, even in adults, the cerebral disturbance has been great-and, finally, when the perspiration has not been abundant- when such circumstances arise-it may be concluded that the case is to be confluent. But there is another sign, independent of the symptoms now enumerated, by which we may confidently predict the same result, when the disease is normal; and that is, the appearance of the eruption at the end of the second day, or not later than during the third day. In normal distinct small-pox, as I have already said, the eruption is generally delayed till the fourth, or even till the fifth day. These remarks, however, are only applicable to the normal course of the two forms of the disease, for in some bad cases, malo semper omine, as Sydenham and Borsieri observed, the eruption does not come out till the fifth, sixth, or seventh day, or even later. Diarrhoea is very often observed in confluent small-pox from the com- mencement of the illness, both in adults and children, but particularly in 74 CONFLUENT SMALL-POX. the latter; whereas, in distinct small-pox, as I have already mentioned, constipation is the rule, at least in adults. This diarrhoea, which is most common in children, continues not only to the fourth and fifth day of the disease-the second and third of the eruption-but even to the ninth and tenth ; and in young subjects it takes the place of salivation, which in adults is a leading feature of the confluent form. While in the distinct form, on the appearance of the eruption, the fever ceases, or at least diminishes to such an extent that the patient is free from discomfort and seems restored to health, it does not at all abate in the confluent form when the eruption comes out; on the contrary, it goes on, and even increases, up to the eighth day, and, indeed, sometimes up to even the thirteenth day. Here you no longer find the period of initial fever from the first to the fourth day, and the period of maturation fever from the eighth to the tenth day. The fever is continuous from the beginning of the illness to the end of the second week, or often to a later date. There is a reduction of heat for not more than twenty-four hours, to the extent of one degree. During the suppura- tion of the pustules, the temperature may rise to, or even exceed, forty-one degrees. The confluent is still further characterized by three great phenomena not seen in the distinct form. I have already alluded to salivation. I now add great tumefaction of the face and swelling of the hands and feet. The two last-mentioned symptoms do not exist in distinct small-pox, or at least if they are present when the eruption is rather abundant on the extremities, it is in an insignificant degree as compared with what is met with in the confluent form. Salivation is almost never seen in distinct small-pox. Let us now attend to the characteristic features of the eruption in con- fluent small-pox. On the first day of the eruption-the end of the second or beginning of the third day of the disease-a redness appears on the face, which, unless it be closely examined, has a diffuse aspect. This redness is so great on the following day, that it is often impossible to know whether the eruption be that of small-pox or measles. This is a point on which Sydenham lays great stress, remarking, in reference to external appearances, that the erup- tion of confluent small-pox coming out, nunc erySipelatis ritu, nunc morbil- lorum, it is very difficult for those who have not had great experience in the two diseases to avoid confounding them, unless attention be paid to the general phenomena of the case; though with this precaution it is impossible to mistake the one for the other. It is not till the third day of the disease that notable projections are visible on the countenance. The diffuse patches of redness, which at an earlier stage might have been mistaken for measles, have now become pap- ules, some of which already contain a little milky fluid. On the face the papules have hardly any space between them, so that when the hand is drawn across the forehead or cheek of the patient, the inequalities on the surface of the skin can scarcely be detected. The papules, besides being smaller than in distinct small-pox, have a less determinate form, running more or less into each other. However, towards the fifth day-the seventh day of the disease-their projection from the surface is more appreciable, and the swelling of the face, although far from having attained its maxi- mum, is universal. The epidermis is elevated by a slight secretion of a milky appearance, and on the following day patches are to be seen similar to those produced by the application of a blister. This kind of vesication is sometimes so general that the face looks as if it were covered with a mask of whitish-gray paper, of an opaline lustre, like papier Joseph or parchment: "Perg amende speciem visu horrendain (cutis facei) exhibet," as Morton said CONFLUENT SMALL-POX. 75 in his " Pyretologia." This is the pathognomonic symptom of confluent small-pox; it is never met with in the distinct form of the disease, except in a very limited degree, when the pustules, being coherent, form a few iso- lated patches. The swelling of the face increases up to about the end of the ninth day, when it has attained its maximum ; it remains stationary on the tenth, and ought to begin to decrease on the eleventh day. The head and face, par- ticularly at the angles of the jaws and around the ears, are much swollen -as much and more than in erysipelas; the eyelids, though less swollen than in distinct small-pox, participate in the general tumefaction of the face, and for four, five, or six days the patients remain without opening their eyes. The eruption does not spare even the globe of the eye; it involves the conjunctiva and cornea, and so gives rise to more or less severe oph- thalmia, leading to perforations and purulent discharges, which may ulti- mately involve complete loss of vision. I shall now resume consideration of the character of the eruption, and particularly the subject of the universal uplifting of the epidermis, caused by the confluence of the pustules. This sometimes proceeds to such an extent that the surface of the skin presents the appearance of one large phlyctsena. About the eleventh day (and not on the eighth, as in distinct small-pox) the phlycttena becomes yellow, begins to be wrinkled, and ex- hales a horrible stench, which is never present in the distinct form of the disease. From the second, sometimes from the first day of the eruption, salivation sets in. At first, the secretion consists of a fluid resembling clear saliva, slightly viscous, but the viscidity of which increases on the succeeding days, while at the same time the amount of fluid secreted goes on increasing till the sixth or seventh day of the eruption (eighth or ninth of the disease), when it is so enormous in quantity, that a patient will give off from one to two litres.* The inconvenience arising from this discharge is very great, and prevents the patient from sleeping. When he does fall asleep, with his bead resting on the pillow, a constant flow of saliva inundates the bed, and, awaking, is followed by great discomfort; finally, he is tormented by a burning, inextinguishable thirst. The salivation is coincident with the ap- pearance of pustules on the inside of the mouth, veil of the palate, and pharynx. I say salivation is coincident with, not that it is dependent on, the presence of pustules on the mucous membrane of the mouth. The salivary excretion may be connected up to a certain point with extension of the inflammatory excitement to the glands; but it is no less true that excessive salivation in confluent small-pox is a phenomenon in some degree independent of this excitement, and dependent, perhaps, upon the essential nature of the disease. In proof of the accuracy of this statement, it is im- portant to call attention to the fact that salivation does not take place in distinct small-pox, even when there are numerous pustules on the buccal mucous membrane. We had an example of this in a young man, who, in July, 1857, lay in bed No. 11 bis, St. Agnes's Ward. He had distinct small-pox, with an abundant eruption on the inside of the mouth, and yet there was no salivation. On the third day of the eruption, evidence is afforded of the existence of the pustules, which become confluent, and cause inflammation of the entire mucous membrane of the mouth and pharynx. The swelling is greatest on the sixth day of the eruption, when also, as I formerly stated, the salivation * A litre is rather more than a British Imperial quart.-Translator. 76 CONFLUENT SMALL-POX. is most abundant; it continues till at least the ninth or tenth day, the sali- vation likewise going on, and lasting one or two days after the swelling has somewhat subsided. There is, therefore, another cause for the salivation, as was well illustrated by the case of a young girl, who occupied bed No. 7 of St. Bernard's Ward. Every day she filled three or four spittoons. She stated that the act of spitting excited violent pain in the throat, which pre- vented her from swallowing the saliva. She was equally unable to swallow beverages, which she rejected after rinsing the mouth with them. I would not, however, maintain, gentlemen, that in this case salivation resulted solely from dysphagia, for in scarlatina, for example, in which there generally is very violent sore throat, salivation is not observed. Salivation, therefore, is a complex phenomenon, for which, although a certain number of causes may be assigned, it is not easy to give to each its proper share. The patient coughs; his voice assumes a certain degree of hoarseness. These symptoms are explained by the affection of the larynx, to which organ the inflammation is propagated from the mouth and back of the throat, and which is also often invaded by the eruption. The laryngeal affections are not without gravity, for it sometimes happens that in conse- quence of them, patients are suddenly carried off by fits of suffocation. You may have seen three cases of this kind in this hospital. Three small-pox patients, at the eighth day of the disease, which had run a perfectly normal course, were suddenly seized with a fit of suffocation, which carried them off in a few seconds, before there was time for any one to come to their assist- ance. In one of them there was found, on examination after death, indica- tions of inflammation of the larynx, and variolous pustules below the glottis. The salivation has generally reached its maximum about the ninth or tenth day of the disease, and on the following day; consequently, on the eleventh day of the disease, or occasionally a little later, it begins to de- crease, and at the same time the swelling of the face diminishes. At this stage appears a symptom not less momentous than the salivation and swelling of the face; it is swelling of the hands and feet. This is an essential part of an attack of confluent small-pox; it succeeds the saliva- tion, and still more the swelling of the face. When it fails to appear the patient almost invariably dies. Since I began practice I have only seen three patients recover from confluent small-pox, without having swelling of the hands and feet, after the subsidence of the salivation and tumefac- tion of the face. Of the three individuals to whom I now refer, one was in our wards two years ago; another was our patient during the current year, and some of you may have seen him, and may recollect that he was very ill indeed ; for more than four months he suffered from large abscesses and numerous very painful boils on the limbs and other parts of the body. The third was a young man who occupied bed No. 12 of St. Agnes's Ward, in August, 1861. He reached the thirteenth day of an attack of confluent small-pox without having had any tumefaction of the extremities. The general symptoms were so grave that we were despairing of his recovery. Under these circumstances I resolved to subject him several times a day to ablutions with cold water, giving him, at the same time, the sulphuric lem- onade recommended by Sydenham. To our great joy, he was somewhat better next day, and in four days convalescence was established, although there was no swelling of the hands or feet. Is not the red oedema of the hands and feet seen in confluent small-pox simply a consequence of a natural determination to these parts, in itself salutary, and proportionate to the number of pustules which are proceed- CONFLUENT SMALL-POX. 77 ing to normal inflammatory evolution ? If it be so, we can understand why cold affusions, by acting energetically upon the whole system, may re- establish the functions of the skin, and bring the disease back to its normal course. The tumefaction of the extremities sets in at the end of the ninth day with rather acute pain, which on the eleventh or twelfth becomes very violent. The swelling and pain then cease. It is a symptom similar to the swelling of the face, and, like it, depends on the maturation of the pus- tules. As in distinct so in confluent small-pox, the face-pustules attain their full development sooner than those on the body ; and they are smaller than in the distinct form of the disease. The pustules mature more quickly on the trunk than on the extremities; concurrently with the inflammation which arises around the pustules (commencing about the tenth day, and attaining its maximum on the eleventh or twelfth), it is not surprising that the extremities should swell, and that the swelling of the face should cease. But the great question to be determined with reference to the swelling of the hands and feet is, What is the value of this symptom ? Sydenham, Morton, Van Swieten, and Borsieri attached immense importance to it, and in relation to prognosis I wish again to insist on its great value, and to re- peat that swelling of the hands and feet is a necessary phenomenon in con- fluent small-pox, that patients almost invariably succumb when it is absent, unless there be a great critical discharge by the kidneys or bowels. When there is absence of the swelling of the hands and feet diarrhcea is as bene- ficial as it is to be dreaded in opposite circumstances. This opinion was held even by Sydenham and Morton, who, as a general rule, considered purging a formidable complication. Swelling of the extremities, which is the rule in confluent small-pox, is an exceptional occurrence in the distinct form of the disease, and is only met with in it when the pustules are numerous on the hands and feet. In a young woman, whom we had as a patient in the Hotel Dieu, in January, 1861, with normal distinct small-pox, although she bore three true vacci- nation marks, there occurred tumefaction of the hands and feet at the end of the ninth day, when, however, the face and neck were still very swollen. The swelling of the hands and feet continued to the thirteenth day. At the beginning of confluent small-pox, as I have already said, nervous symptoms appear pretty frequently, such as tremors and sometimes slight delirium. When this delirium is met with, it generally occurs as a tran- sient phenomenon just as the eruption is coming out, and returns about the third day of the eruption (fifth of the disease), and continues to the end of the attack, or at least to the thirteenth or fourteenth day of the disease. When it is violent-when it assumes the form of typhic delirium-when it is accompanied by coma vigil, picking the bedclothes, and twitching of the tendons, its prognostic significance is exceedingly grave. The same may be said of diarrhcea. It generally shows itself in the early days of the disease, and ceases about the fifth day from the date of the in- vasion, that is to say, about'the second or third of the eruption; but when it continues, and is violent about the eighth, ninth, and tenth days, the prognosis is unfavorable, except in the exceptional conditions formerly men- tioned ; in ordinary cases patients who have violent diarrhoea at or after the eighth day almost always die. This, however, was not the opinion of Hoffmann, who, so far from dreading diarrhcea, even when violent, in con- fluent small-pox, looked upon it as beneficial; but the opposite opinion, which I hold, is that of Sydenham, Morton, and Borsieri. When the eruption has reached its thirteenth or fourteenth day, just when the swelling, which has for two or three days left the face, appears in 78 CONFLUENT SMALL-POX. the extremities, the patient exhales, as I have already said, an insupport- able fetor. If you raise the bedclothes you are shocked with the disgusting smell which comes from the putrefaction of the pus exuded by the pustules. This putrefaction has, perhaps, something to do with the serious complica- tions which occasionally supervene at this period. There may be absorption of the putrescent fluids and miasms, poisoning the blood, and producing in that -way the grave symptoms which arise. I dare not, however, assert positively that facts are in exact harmony with this theory, which has Bor- sieri as a supporter. With a view of preventing the dreaded purulent in- fection, some practitioners, as you are aware, are in the habit of opening the pustules as soon as possible, and bathing the skin very frequently with chlorinated lotions. This practice, at least to the extent of opening the pustules, was followed by the Arabian physicians Avicenna and Rhazes. Ambrose Pare also adopted it. It may be very beneficial; but its perform- ance must, in my opinion, be often exceedingly difficult. The baths have likewise great utility, as have all measures which conduce to cleanliness- a maxim strongly put by Van Swieten, when he recommended that the patients should have their linen changed frequently. It must be clearly understood, however, that such proceedings demand great precautions, and that in our hospital practice it is sometimes very difficult to carry out the very useful precepts now noticed. As the disease advances, as the patient enters the third week, the delirium, which had continued up to the thirteenth or fourteenth day, ceases; the fever, however, continues, and generally goes on till the twentieth, twenty- first, or twenty-second day, which is accounted for by the persistence of the violent inflammation of the skin, still almost entirely covered with pustules more or less deeply ulcerated. Then, however, the crusts formed upon the ulcerated surfaces present the appearance of ecthyma crusts; they become detached, leaving the dermis more or less scooped out. New crusts, thinner than their predecessors, then form; they also fall off, and are succeeded by others thinner still; and so on during two, three, or four weeks, crusts suc- ceed each other on the small ulcerations which ultimately cicatrize, leaving the scars more or less rugged, which seam the faces of persons who have gone through confluent small-pox. After the fourth week of the disease it often happens that the fall of the crusts is followed by a true furuncular diathesis. Patients may have, on the surface of the body, as many as twenty, thirty, or even a hundred boils, causing excruciating pain, and succeeding each other so as to maintain the crop for from two to six months. The tendency to suppuration, consecutive to confluent small-pox, not only shows itself in an outbreak of boils, but also by the formation of abscesses more or less deepseated. Too often these abscesses prove very dangerous complications. We see our convalescent patients suddenly seized with rigors and the most intense fever; they complain of pain in the deepseated mus- cles ; and the fluctuation detected on examining the parts gives clear evi- dence of the existence of a more or less" considerable collection of pus to which it will be necessary to afford an exit. The abscesses, like the boils, go on in succession for from two to six months, unless the patient unfortu- nately succumbs previously, as is generally the case, exhausted by the pro- tracted suppuration. Almost always these abscesses occur in the limbs. Sometimes they are situated around the anus, and give rise to detachment of the rectum from the surrounding cellular tissue, necessitating, at a later date, the operation for fistula. In some still rarer cases the abscess may be more deeply seated, and cause dreadful complications. On the 7th February, 1861, we performed the autopsy of a lad who died CONFLUENT SxMALL-POX. 79 after an attack of confluent small-pox, whom you saw when he occupied bed No. 21 of St. Agnes's Ward. During convalescence he had numerous boils and subcutaneous abscesses, some of which opened spontaneously, and others of which were opened by us. He nevertheless complained of acute pain in swallowing, which I attributed to the persistence of an inflamma- tory condition of the pharynx and curtain of the palate, which existed when the small-pox was running its course. About the end of January, when an epidemic of influenza was prevailing, he was seized with acute bronchitis, and we soon afterwards detected slight pleurisy at the back of the left side of the chest. The inflammation of the chest seemed to have moderated, when, on the 5th of February, I found him unable to breathe in the horizontal position, with difficult, wheezing inspiration, and very laborious expiration; the symptoms of oedema of the glottis were unmis- takably evident; I was under the impression that there was necrosis of a portion of the larynx, and erysipelato-phlegmonous inflammation of the aryteno-epiglottidean folds. I ordered a solution of tannin to be applied to the back of the pharynx by means of the apparatus of Mathieu, and at the same time directed that everything should be in readiness for trache- otomy. At four in the afternoon the symptoms had become so formidable that the sister of the ward summoned the chaplain before she sent for the interne on duty; when the latter arrived, the patient was dead. You will recollect that, on examination after death, we found oedematous inflamma- tion of the aryteno-epiglottidean folds, and an abscess, as large, as a pigeon's egg, between the oesophagus and back of the larynx; this abscess, limited in front by the denuded cricoid cartilage, spread under the cellular tissue within the larynx, and bulged out considerably into the larynx above the vocal cords. It is not usual for oedema of the glottis to occur in this manner in cases of small-pox. It appears, as I have already said, between the ninth and twelfth day of the disease, when the eruption is very confluent on the mu- cous membrane of the throat and larynx; the tumefaction of the aryteno- epiglottidean ligaments comes on as does that of the eyelids and hands; and you have seen a young man die in our wards, in a few hours, suffocated by this form of variolous cedema of the glottis. But, gentlemen, you can remember a young woman in St. Bernard's Ward, in 1860, who, about the twelfth day of an attack of small-pox, was seized with dyspnoea, hoarseness, and wheezing inspiration, and who, nevertheless, was completely and quickly cured by injecting a saturated solution of tannin into the back part of the throat. We have lately had an opportunity of observing a case of distinct small- pox in a child of twenty months, which is full of clinical instruction. This patient, on the third day of the eruption, was seized with dyspnoea, which seemed to be chiefly dependent on oedematous laryngitis. Tracheotomy was performed: at the moment of opening the windpipe, two false mem- branes were thrown out through the wound. The child died a few hours after the operation. An autopsy showed that the small-pox had been com- plicated by a pseudo-membranous inflammation extending to the larger bronchial tubes; on the right side there were isolated masses of purulent pneumonia, and on the same side a small quantity of purulent effusion. This is an exceedingly rare complication, but still it is well to notice it to you. I take this opportunity of remarking that all inflammatory action has a great tendency to become purulent in cases of small-pox, and that we see this in the inflammatory affections of the cellular tissue and parenchyma of organs. But, in addition to this tendency, the result of a special dia- 80 CONFLUENT SMALL-POX. thesis which belongs to small-pox, another complication may arise, viz., metastatic abscesses presenting analogous general symptoms to similar col- lections of pus occurring after amputations and in puerperal women. This manifestation of metastatic abscesses begins particularly between the ninth and fourteenth day of the disease, that is to say, when the skin is covered with a sheet of pus. Possibly there exists at this time capillary phlebitis, as the starting-point of the purulent infection, a view maintained by Kibes, and which Legallois has endeavored to establish in his essay on purulent infection. The existence of capillary phlebitis in small-pox has not been demonstrated, but the hypothesis of its presence becomes very truthlike when we recollect that we sometimes meet with erysipelas of the arms and legs in confluent small-pox; in these cases the lymphatic vessels or veins may participate in the purulent inflammation of the skin, and become the cause of infection. It is only in exceptional cases that distinct small-pox is fatal; but wre have said enough to show that it is far otherwise with the confluent form of the disease. The history of epidemics proves this: in some epidemics, the half; in others, four-fifths; and in others, less fatal, we find that one- third die of those attacked. It is therefore the most deadly of all pesti- lences ; the mortality is much in excess of that from yellow fever or cholera. The terrible feature of small-pox is, that it not only kills in the acute stage, but even after it seems to have left the patient, and when all danger ap- pears to be past. It proves fatal by the deepseated suppurations of which we have spoken-suppurations which invade the cellular tissue of the limbs, and likewise become developed in the serous cavities, more frequently in the pleurae than in the peritoneum; it proves fatal by peri-pneumonia, which rapidly proceeds to suppuration, and that so late as the second or third month from the beginning of the eruptive fever. We are then right in saying, and repeating, that small-pox is the most formidable of epidemic diseases; for while other diseases strike down their victims, they rarely do so during convalescence. In small-pox, when death occurs during the course of the disease itself, it occurs at a period which it is necessary to indicate, inasmuch as it is of the highest importance to know when to expect the fatal issue so that we may be able to foresee and predict it. In confluent small-pox the patient very seldom dies before the eleventh day, and, in general, the most fatal epochs are the twelfth, thirteenth, and fourteenth days. However alarm- ing the symptoms may be, even when death seems imminent on the seventh or eighth, we may hope that life will be prolonged at least to the eleventh or twelfth day. Sometimes, nevertheless, the disease terminates fatally within the first five or six days, but this is only when it has assumed an anomalous form, and is of an exceptionally malignant type. Quite suddenly, and without apparent cause, the strength fails, unusual symptoms, not in accordance with the ordinary course of the disease, show themselves; there is a formidable increase in the nervous symptoms-in the delirium, coma, prostration, anxiety-and also in the dyspnoea, although there is no ap- preciable thoracic lesion. A rapidly fatal issue is particularly apt to take place in those frightful cases of hemorrhagic small-pox of which we had some in the hospital, and of which I shall immediately speak. Anasarca, which supervenes in the last period of scarlatina, and occa- sionally, though rarely, at the end of an attack of measles, also occurs in confluent small-pox; it is rarer than in scarlatina, and more frequent than in measles. Albuminuria is almost as common in confluent small-pox as in scarlet fever. There is this difference, however, that in scarlatina the albuminuria CONFLUENT SMALL-POX. 81 appears during the decline, and in confluent small-pox during the acute period of the disease. Extensive observations made by Dr. Abeille* have shown that, in confluent small-pox, as in scarlatina, albuminuria is met with in about one-third of the cases. Developed at the beginning of the attack, the renal affection may continue to the end of it, so as then to present a kind of analogy with scarlatinous albuminuria. Although albuminuria does not show itself nearly so often during convalescence from small-pox as in the decline of scarlatina, the occurrence is sufficiently frequent to be remembered as a possible complication. The same remark applies to hcem- aturia, an affection which often precedes and announces the existence of scarlatinous albuminuria. It is rarer in confluent small-pox than in scar- latina ; and when it does occur, it is at the commencement of the disease, and not during the period of its decline. Independently of the cases in which the hsematuria is connected with Bright's disease of more or less transient character [affection Brightique plus ou moins passagere de reins], there are others in which passing blood by the urethra constitutes an epiphenomenon of the most serious import. Such is it when coincident with nasal, buccal, bron- chial, and subcutaneous hemorrhages, as in the terrible forms of the malady described by the ancients as variolce nigrce, or black small-pox. Many of you, gentlemen, ought still to recollect two cases of this kind which we saw, in 1860, in the wards of our colleagues, Drs. Legroux and Pelletan. The two patients to whom I refer had bleeding from the nose, mouth, eyes, anus, urethra-in point of fact, from all the emunctories -accompanied by a general subcutaneous eruption of frightful intensity, of a violet-red color, like the lees of wine, so that the individuals looked as if they had been soaked in vats full of the residuum of pressed grapes. You recollect that some of the pustules were stained reddish-black by the blood with which they were filled, and you were, no doubt, particularly struck by the small number of the pustules, although the date of their appearance, within forty-eight hours of the pyrexial invasion, left no room to doubt that the disease was confluent small-pox. Some years earlier, in 1854, we had analogous examples in our wards. But in them-to which I shall return when I speak of measly and scar- latinous eruptions in modified small-pox-in them the hemorrhagic compli- cations were essentially milder, and had not the disastrous consequences seen in the other two cases, the small-pox having been modified by antece- dent vaccination. The two unfortunate patients of 1860 were seized with delirium, restlessness, and high fever, and sunk rapidly from the beginning of the attack. In young children small-pox presents important peculiarities in its onset, course, and issue. In them the period of incubation is the same as in the adult, viz., from nine to eleven days. The initiatory symptoms often pass unobserved, because the little patient cannot tell what he feels; still, the experienced clinical observer will always be on the outlook for the eruption of small-pox, when he meets with quick pulse, vomiting, diarrhoea, restlessness, convul- sions or coma, in an unvaccinated child, whose previous morbid condition was inadequate to explain the appearance of these symptoms. Two or three days after these epiphenomena a variolous eruption, distinct or con- fluent, is observed. It appears on the surface of the skin, in successive out- breaks ; in some places it may be distinct, while it is confluent in parts where there is a previously existing cause of irritation, as on the hips and other * Abeille : Traite des maladies a urines albumineuses et sucrees. vol. i.-6 82 CONFLUENT SMALL-POX. parts irritated by the contact of the urine and the swaddling bands. The development of the pustules in children differs in no respect from their de- velopment in adults; but the younger the patient is, the more reason is there to fear that the course of the disease will be anomalous. Thus, it is not uncommon in infants of one, two, or three months to see the eruption fade on the first day of the appearance of the papules; under such circum- stances, the surface of -the body is very pale, and the papules have an opalescent aspect. At other times, and particularly about the second, third, or fourth day of the eruption, it has a hemorrhagic appearance, the herald of a speedy and fatal issue; the patients remain drowsy, with small, thready, irregular pulse, and they die without a struggle. It sometimes happens that immediately after the first outbreak of the eruption, they take the breast eagerly ; their skin continues hot, their pulse somewhat frequent, but regular, and they support well the fever of maturation. Infants above a year old may recover, but under that age almost invariably die. On the fourteenth or fifteenth day, just when we are believing that the case is pro- gressing favorably, death takes place, either without a struggle, or after one or two fits of convulsions. These remarks show how very reserved we ought to be in our prognosis of small-pox in childhood, even when to all appearance the case seems to be going on well. Small-pox, confluent or distinct, is almost always fatal in children under two years of age; they may be carried off without having had any of the complications looked upon as so inauspicious in adults. When death occurs during the first few days, it seems to be caused by variolous toxaemia; when it occurs later, say about the third week, it is apparently the result of the long struggle having exhausted the vital power of the patient. Need I recall to your recollection that, in distinct small- pox in children, diarrhoea is not a serious complication, that on the con- trary, it seems, like perspiration in the adult, to be a favorable symptom ; that in them, in the confluent form of the disease, it takes the place of sali- vation, and ceases spontaneously on the appearance of tumefaction in the hands and feet? Young children, when they do not succumb, often have, like adults, numerous abscesses on the surface of the body. As it is, for obvious reasons, in the wards of an hospital, that there is the most danger of contracting small-pox the physician in charge ought at once, on the admission of children, to inquire whether they have been vaccinated ; and if they have not, his first care ought to be to have the operation per- formed, unless there are circumstances which constitute a positive contra- indication. The treatment of true small-pox, distinct and confluent, has now to be considered. Necessarily, I shall be brief on this subject, for there is rarely room for energetic medical interference in the eruptive fevers. These dis- eases run a natural course, which is inevitable and definite; this remark is strictly true in respect of measles' and scarlatina, but its correctness is even more strikingly manifest in small-pox, the different periods of which are distinctly determined, mathematically limited, so to speak, according to the form of the disease being distinct or confluent. Distinct small-pox is generally a mild malady, and may generally be left to itself. We may rest satisfied with prescribing cooling beverages, and slightly acidulated diet-drinks, such as lemonade, orangeade, and cur- rant-water. Confluent small-pox, unfortunately, does not call for any very different treatment. In recent times, the advantages resulting from the employment of certain medicines have been vaunted, but the facts upon which such MODIFIED SMALL-POX. 83 opinions rest are far from being conclusive. My practice is, excepting when there are complications involving special indications, to confine myself to prescribing diet-drinks acidulated with sulphuric acid, as recommended by Sydenham and Van Swieten under the name of antiseptics. When there is much cerebral disturbance, baths and the cold affusion do real service, though less than in scarlatina. Baths and lotions, not exactly cold, but of a moderate temperature, demand a very important place in the hygienical treatment of small-pox. We have already seen that some prac- titioners bathe their patients frequently with a view of preventing the purulent infection likely to result from the formation and stagnation of variolous pus on the surface of the body. It is an equally useful measure to change the linen frequently ; and without going the length of Van Swieten, who inculcates exposing it to the vapor of aromatic substances, to get rid of the lye and the soapy smell, one cannot be too careful as to the way of carrying out in practice the frequent change of linen. The risk of exposing small-pox patients to cold air has been exaggerated. Sydenham combated the erroneous opinion that persons suffering from eruptive fevers ought to be kept in rooms at a high temperature ; there is nothing so danger- ous as this vulgar prejudice, which caused patients to be smothered under a load of bedding, and to be placed in chambers having every chink stopped up, and the airing of which was hardly ventured upon. Cold is less dan- gerous than excessive heat. For this reason, Sydenham prohibited the too much covering of small-pox patients, and in distinct small-pox, in warm summer weather, he did not confine them to bed. Cullen and Stoll went still further, and directed that they should be exposed to moderately cool air. Diarrhoea in confluent small-pox is a terrible complication when it con- tinues till the eighth, ninth, or tenth day; it requires to be kept in check by small doses of opium, but constipation must be equally guarded against. This was the opinion of Sydenham, Freind, Lobb, Huxham, and many others. Morton himself, who so much dreaded intestinal flux, recommended, nevertheless, the employment of lavements, and even of purgatives, when the patients were without stools, and the reaction excessive; he advised similar means to be resorted to when it was desirable to excite a salutary crisis, in consequence of salivation ceasing, without the swelling of the extremities taking place. In small-pox, as in typhoid fever, it is not judicious to place our patients on too low diet; they ought to have meat broth, and light soups, made with or without meat, should be given frequently and in small quantities through- out the twenty-four hours. Modified Small-pox.-Does not differ from true Small-pox in its essence. -It differs from Varicella or Chicken-pox.-It was well known before our times.-In the period of Invasion it is Identical with Small-pox.- Scarlatiniform and Petechial Eruptions at the commencement.-Black Small-pox.-Particular Modes of Desiccation.-Is seldom a dangerous disease. Gentlemen: Let us now attend to the subject of modified small-pox. In recent times a proper custom has arisen of designating by the terms rheumatoid pains and diphtheroid exudations, the pains and exudations which resemble rheumatic pains and diphtheritic exudations, the object of using these new names being to point out that there is only an analogy in the manifestations, and not an identity in the nature of the maladies; thus, the pains which belong to syphilis may be called rheumatoid, and we may 84 MODIFIED SMALL-POX. designate as diphtheroid the pultaceous exudations which proceed from certain inflammatory affections of the mucous membranes of the mouth and genital organs, not in any way dependent upon the general disease named diphtheria. If it was right to introduce this phraseology, it would be wrong to continue to apply the term " varioloide " to modified small-pox, as it would leave room for supposing that the natural and modified diseases are essentially different from each other. Henceforth, therefore, we shall sub- stitute for the word "'varioloide" the expression "variole modifie." Modified small-pox has been observed long ago. Such of you as would wish to read the histories of anomalous epidemics of small-pox by Syden- ham, the "Commentaries" of Van Swieten, and the Institutes of Borsieri, will be soon convinced that long before the discovery of vaccination persons had been observed to be affected with a form of small-pox presenting all the characteristics of the modified small-pox of the present day. The modified disease showed itself in those who had had small-pox previously, whether communicated by accidental contagion, by intentional inoculation, or by intra-uterine communication ; this has been demonstrated beyond the possi- bility of doubt in our day, and was perfectly well known to the ancients. One cannot too often peruse and reperuse the interesting passage in the "Commentaries" of Van Swieten on Boerhaave's "Aphorisms," in which, when discussing the subject of second attacks of small-pox, the illustrious physician of Vienna describes several kinds of modified or bastard small- pox, although he has confounded under the name of variolce spxurice chicken- pox and small-pox, which are essentially different from one another. Modified small-pox is simply small-pox modified either by antecedent small-pox, or by antecedent vaccination. Varicella or chicken-pox is, on the contrary, a special and specific malady, having no relationship whatever with small-pox. It is easy to demonstrate the truth of both statements. When we come to study varicella we shall see that it never engenders small- pox, just as small-pox never engenders varicella. Again, vaccination has no preventive influence against varicella. With respect to modified small- pox, we see that it is very different. If a patient suffering from natural small-pox, distinct or confluent, enter a ward where there are individuals who have been vaccinated, but who no longer enjoy the vaccinal immunity in a sufficient manner, these individuals may take the disease; but it will present features different from those of natural small-pox; they will, in fact, have modified small-pox. Again, if a patieut affected with modified small- pox, in its simplest and mildest form, be placed in contact with one who has neither had small-pox nor been vaccinated, the latter may contract the disease; and if so, it will not be the modified form, but natural small-pox, distinct or confluent; he, in his turn, may communicate the variolous con- tagion to a third person, in whom the case will assume the natural or modi- fied form, just as he has or has not been vaccinated-that is, just as he may be in the condition of the first or second patient. Such cases as I now refer to you-have seen; they are quite sufficient to demonstrate, rigorously and incontestably, the absolute identity of the modified and the natural small- pox. This identity may also be demonstrated in another and more direct manner. An imperious necessity has several times obliged me to practice inocula- tion, both in this hospital and in my wards for children at the Necker Hos- pital. Having no vaccine lymph, and small-pox being prevalent in the wards, I hoped by inoculation to impart a milder form of the disease than that which the persons I inoculated might contract from the patients who had small-pox. You can understand that, under such circumstances, I only inoculated with virus taken from a case of modified small-pox, in which the MODIFIED SMALL-POX. 85 characters of the distinct form of the disease were as well marked as I could possibly find them. Now, in spite of that precaution, I always communi- cated natural small-pox, of the distinct form, it is true, but still umistakable, natural small-pox. So legitimate was the disease I imparted, that if some days after recovery I introduced the vaccine matter into one arm, and the variolous matter into the other, neither declared themselves. The individual had lost his aptitude for contracting the disease, which, like the other erup- tive fevers, does not attack the same person a second time, save in excep- tional cases. Small-pox, natural and modified, are, therefore, identical, because they reproduce natural small-pox. During the first quarter of this century the existence of modified small- pox was almost disputed. However, at the London Small-pox Hospital persons were from time to time received who said they had been vacci- nated ; and Jenner himself avows having seen some such cases; but as there was a desire at that time to make out that vaccination could never fail, it was alleged that vaccinated persons who took small-pox had been badly vaccinated, and their attacks were looked upon as natural small-pox. At last evidence became irresistible, when, about the year 1822, epidemics of small-pox were seen to strike vaccinated populations, when three years later they reached Paris, where in recent years they have continued to prevail. The influence which the variolous matter exerts on the economy, and the modifications which it imprints on the organism, being necessarily subordi- nate to the predisposition acquired by the organism under the variolous influence, or (which is the same thing) under the influence of antecedent vaccination, it necessarily follows that a second variolous inoculation will produce on the economy various effects proportionate to the degree of im- munity previously conferred upon it, and which it still possesses more or less completely. Also, although modified small-pox is in its essence iden- tical with natural small-pox, it is far from being identical in its forms. In place of having, like natural small-pox, fixed and precise features, it even presents essential differences from itself, and has no settled character. So correct is this statement, that the only way to describe modified small-pox is to speak of each of its numerous varieties as I now propose to do. There is one period in which modified is always identical in symptoms with natural small-pox; that is, the period of invasion. However much attention you may bestow upon initiatory phenomena of the disease, it will be as impossible for you as it was for me to establish a difference between symptoms of each during that period. Rigors followed by heat, anxiety, headache, pain in the epigastric region, nausea, retching, vomiting, pain in the back, feebleness, paralysis of the inferior extremities and bladder-such is the train of prodromic symptoms which alike supervene in modified and natural small-pox. In both the symptoms are mild, if the case-be it natural or modified small-pox-is going to take the distinct form; and in both they are more or less violent, if it is going to take the confluent form. The eruption comes out on the same days and in the same manner; that is to say, on the fourth day in the distinct, and on the second or third in the confluent. Here, thermometric investigation furnishes valuable information ; thus, for example, the temperature, which had risen as high as 40 or 41 degrees, suddenly falls to about 37 degrees on the appearance of the eruption. This rapid decrease of heat takes place continuously, and not slowly, as in distinct small-pox. The rapid subsidence of heat may enable us to diag- nose modified small-pox, when from the apparent gravity of the symptoms, we might have supposed that the case was one of natural small-pox. Let me add that, in modified small-pox, we begin, as pustules appear, to dis- 86 MODIFIED SMALL-POX. cover some of the characters of anomalous small-pox described by Syden- ham, such as a premature appearance of the eruption in the distinct, and a retardation of it in the confluent form. Delirium, as we have seen, may supervene in confluent small-pox during the period of invasion, and continue to the end, the patients dying about the twelfth day. In modified small-pox, cerebral complications are ob- served more frequently than in natural small-pox; but there is this capital difference, that they have not an unfavorable prognostic signification in the former. Last year, among others with modified small-pox, we had some in our wards who were a prey to violent delirium, which, after continuing, not only on the morrow of the eruption, but also for the two or three fol- lowing days, ceased abruptly on the seventh or eighth day of the disease, when the patients became convalescent. It is more common to meet with anomalous cutaneous eruptions, accord- ing to the prevailing epidemic constitution, in modified than in unmodified small-pox; they appear the day before or simultaneously with the pustular eruption. Sometimes they so much simulate, as to be mistaken for, the eruption of measles, even when they are looked at closely ; still more do they sometimes resemble the exanthem of scarlatina. The spots are small, of a more or less deep red color, sometimes blackish, nearly always running into each other, so as to form large patches, hemorrhagic-looking, to which the English have given the name of rash* This is in a slight degree that of which I spoke of to you as black hemorrhagic small-pox, recalling to your recollection the terrible examples we had in the wards of our col- leagues, MM. Legroux and Pelletan. These hemorrhagic scarlatiniform eruptions, which in natural small-pox constitute an alarming symptom, do not lead to an unfavorable prognosis in modified small-pox. They gener- ally show themselves in the groin, on the thighs, and on the lower part of the abdomen. They do not disappear on pressure with the finger, or at least there remains a greenish-yellow mark, which quickly acquires the reddish hue, of a more or less violet shade, momentarily effaced by the pressure of the finger. This rash is sometimes more uniformly diffused; the condition of the patient is then apparently more serious; and I recol- lect that, in 1854, we had in our wards three remarkable cases of modified small-pox, accompanied by hemorrhagic scarlatiniform and measly erup- tions, which presented very alarming symptoms at the beginning of the attack. In two of these cases, to which allusion has already been made, the pa- tients were young women between twenty and twenty-three years of age, who came into the hospital complaining of violent pains in the loins, nausea, vomiting, and rigors ; the pains in the loins were accompanied by extreme debility in the inferior extremities and partial paraplegia. On the third day in one case, and on the fourth, in the other, we saw an erup- tion of small red livid spots, varying in size from a pin's head to a lentil; they did not disappear on pressure. In one of these young women, the eruption was limited to the groins and axillae; in the other, although it was more confluent in these situations, it likewise covered the upper part and base of the neck ; it showed itself on the legs, where it was of a deep shade, and was even disseminated over the entire surface of the body, which pre- sented an appearance of small dots, of a bright rosy hue, which became * The author is evidently not aware that English physicians, as well as the general public, use the term rash when speaking of any exanthematous eruption, and that the word, except with the assistance of one or more other words, does not indicate a special exanthem, nor a particular form of exanthem.-Translator. MODIFIED SMALL-POX. 87 effaced on being pressed by the finger. This eruption was more copious on the following day ; but on that day, which was the sixth from the beginning of the disease, the characteristic eruption of small-pox came out. The hemorrhagic discolorations enlarged still more on the second day from the appearance of the pustules, and during the night the patient had slight bleeding from the nose. She had at that time persistent fever, much delirium, and great restlessness, both of which continued till the eleventh day of the disease. At that date, the greater part of the variolous pustules aborted, and the rest desiccated ; while simultaneously the general symptoms ceased without any treatment. Thus, in this case, there was not only scar- latiniform eruption, but likewise a true nasal hemorrhage ; and between the twelfth and thirteenth day of the disease the subcutaneous sanguineous stains left characteristic traces, some reddish and others yellowish. An additional cause of great anxiety was the continuance of the fever, delirium, and extreme restlessness up to the eleventh day. The nervous phenomena, however, ceased in an abrupt manner, aud the patient recovered. In another young woman, and in a young man whom we had under observation about the same time, the general symptoms and hemorrhagic eruptions were nearly as strongly marked as in the first mentioned of the two young women ; and the issue was equally favorable. We had to do with persons who had been vaccinated, for we found true characteristic vaccinal cicatrices ; and we had to do with modified small-pox. Under such circumstances, even when the symptoms have an alarming aspect, the case generally terminates favorably. I have hitherto spoken of cases of modified small-pox, in which scarlatini- form eruption remained after the appearance of variolous pustules; there are others in which it disappears rapidly, and may escape observation. It is a remarkable fact, and one to which attention was long ago directed, that variolous pustules are either not developed, or are only developed very sparingly in parts where the scarlatiniform eruption exists. I have, gentlemen, been speaking to you of the scarlatiniform, and not of the scarlatinous eruption ; and I have much insisted on the name scar- latiniform, which I have given to it. I wish still more to insist on this name, for I confess that I am at a loss to understand how grave men, hospital physicians, occupying an eminent position in our art, can constantly say and print that small-pox was complicated with scarlatina in cases similar to those which I have just brought under your notice. This deplorable mistake is made by the anatomical school of pathology, which, determining the nature of a disease by one of its manifestations on the exterior of the body, does not take into account the constituent elements of the disease, the aggregate of which represents the morbid unity of which we ought to form a conception. The cases now under consideration have no more to do with scarlatina than with dothienteritis-no more than pneumonia, small- pox, or scarlatina have to do with typhoid fever, when typhoid symptoms appear in the course of an attack of any one of them. Sometimes, though rarely, the eruption is measly. In July, 1862, we received into the clinical wards a young woman in the third day of an attack of small-pox. She had been vaccinated. The symptoms of the initiatory period had been rather severe; but there was nothing abnormal in the aspect of the case. At the visit hour the patient had already some characteristic pustules ; at the same time we found an eruption resembling measles on the hands, posterior aspect of the forearms, on the elbows, knees, and anterior surface of the thighs. It was displayed in irregular patches, separated by oddly-shaped intervals of white. The exanthem was morbilliform, and not scarlatiniform. But some of the red patches on the forearms and thighs presented a very particular character. In the centre 88 MODIFIED SMALL-POX. was a small red papule, around which there was an areola of about a centimetre in diameter. The singularity of the appearance consisted in the injection of the dermis not proceeding outwards from the central papule, and diminishing in intensity as it got nearer the healthy skin ; so far from this being the case, the discoloration was sharply defined by a narrow, bright-red band, between which and the centre, the hue was notably less deep in color. The characteristic eruption of modified small-pox comes out like that of the natural disease. It begins on the face, forthwith gains the trunk and limbs, and finishes with the hands in from thirty-six to forty-eight hours from the commencement of its appearance. It is at first identical with the natural variolous eruption. Like it, it is formed of small red spots, which become acuminated, and then flatten towards the third day. But generally from the third or fourth day of the eruption-the seventh or eighth of the malady-they undergo a remarkable modification, which is never seen in natural smali-pox, whether distinct or confluent. In place of showing a tendency to increase up to the'eighth day-in place of becoming surrounded by an inflammatory areola, and beginning on the nose and chin to be covered with small, yellowish rough crusts, they dry up without exhibiting the inflammatory areola ; and they leave in their place small hard, corneous projections, which fall by a sort of desquamation between the tenth and fifteen days. Such is modified small-pox in its elementary form, and as it is known to the English by the name of " horn-pox." In some cases, however, the pustules continue for from three to six days, or longer. If you examine three patients with modified small-pox at pres- ent in St. Agnes's Ward-one in bed No. 8, another in bed No. 11 bis, and the third in bed No. 17-you will see in the first that the pustules became horny on the eighth day of the eruption ; in the second, they assumed that appearance on the ninth ; and in the third, they did not dry up till the twelfth, thirteenth, and even fourteenth day. These three cases are examples of the varieties of the disease, which they show you is in reality abortive small-pox, and that is only developed on account of the morbific germ having been thrown upon a congenial soil. It appears, in fact, that there are certain diseases, among which small-pox is conspicuous, which, like the seeds of plants when sown in different soils, germinate and grow up in different manners; in soil suited to their nature, they spring up invested with all their natural characteristics, they blossom, shed their seed, and, in a word, attain to perfection ; in a poorer soil they grow with more difficulty, scarcely.blossom, and ripen badly ; in a still poorer soil they germinate, but almost immediately die. The seeds of diseases, like the seeds of plants, are liable to degenerate. The quality of the germ, the receptive power of the soil, whether it be the earth or the human body to which the germ is committed, are not always the same. Under certain circumstances, the organism undergoes a constitutional change in virtue of which it is more or less fitted for the reception and germination of the morbific seed ; hooping-cough, for example, impresses the economy in so special a manner that the same person will not take that disease twice, and the same is true in respect of scarlatina and small-pox. This is most con- spicuously true in respect of the latter, though the explanation of the fact is as inexplicable in the one as in the others. As already said, small-pox and vaccination place the organism in that special condition in which it is incapable of again contracting small-pox. This resistance, however, to the morbific conception is not absolute. Second attacks of small-pox and attacks of small-pox in vaccinated persons do occur, but in such cases the morbid germ does not grow up with its natural characteristics. The effects, MODIFIED SMALL-POX. 89 as I before said, are proportionate to the degree of immunity which has been conferred, and this degree of immunity appears most frequently to depend on the longer or shorter interval which has elapsed between the second attack of small-pox and the antecedent small-pox or vaccination. If the vaccination is of recent date, the nature of the small-pox will be more radically modified, milder, for example, than if twenty-nine or thirty years had elapsed. Side by side with cases of benignant modified small- pox, you will see others which for ten or twelve days follow the exact course of natural small-pox ; the swelling of the face and eyelids takes place, the pustules on the limbs are surrounded by an inflammatory areola, and pain is complained of in the regions which they occupy ; then this swelling subsides more rapidly than in natural small-pox; the pustules on the hands, in place of attaining their maximum of development on the fourteenth, are filled with pus on the eleventh or twelfth, when they wither, instead of waiting till the eighteenth or up to the twenty-second day, as happens in distinct natural small-pox. The disease, in a word, in some individuals, after seeking to exhibit itself in its usual character, suddenly changes its manifestations, and terminates in a rather abrupt manner, while in others it altogether fails to develop itself. In some persons the organism seems so,refractory to the action of vario- lous matter, or, to continue the comparison which we formerly employed, the soil is so ill prepared to receive the morbific germ, that although there has been neither antecedent small-pox nor vaccination, the small-pox, when it is contracted, is modified. Dr. Firmin lately mentioned to me the following case which he had just met with in his practice : A patient had been vaccinated by him, and the vaccination did not take effect. Some time afterwards, when he was thinking of repeating the operation, he was called to see the patient, whom he found suffering from distinct small-pox, which ran a course exactly like that of modified small-pox. Does not this case offer a certain analogy to that of the young woman who now lies in bed No. 18 of St. Bernard's Ward ? She took small-pox a few days after her child, who had just died of that disease in its confluent form. This young woman was never vaccinated, and she never had small- pox, so she said ; and she bore no traces either of vaccination or small-pox. On and after the tenth day, however, the case followed the usual course of the modified disease. The period of invasion was characterized by general discomfort, great lassitude and muscular pains, nausea, and epigastric pain ; of the usual symptoms, rachialgia alone was absent. There are still two circumstances which remain to be noticed. In dis- tinct, natural small-pox, there is a cessation of the fever upon the appear- ance of the eruption, but we see it return on the eighth day, when the pus- tules on the face are beginning to maturate, to continue during the ninth and tenth day, finally to cease on the eleventh. In modified small-pox, even when maturation begins on the eighth day, which is very unusual, there is hardly any febrile excitement, and it does not last for more than twenty-four hours; the temperature in the axilla is likewise at that time hardly raised. In confluent natural small-pox, at the coming out of the eruption, salivation appears, and is the great phenomenon of that form of the disease; then on the fifth day there is swelling of the face, which goes on increasing till the ninth, when it has attained its maximum, at which it remains on the tenth, and on the eleventh it diminishes simulta- neously with the appearance of tumefaction of the extremities. In modified small-pox, even when very confluent, salivation almost never occurs, swell- ing of the face is rare, and when it does appear there is no swelling of the hands and feet. 90 VARIOLOUS INOCULATION. Modified small-pox generally has a favorable issue, but it is not invari- ably a mild disease. Five years ago, I lost a relation by confluent modi- fied small-pox. Delirium supervened at the beginning of the attack, and continued to the last; death took place on the thirteenth day, swelling of the face having previously shown itself. This person had been vaccinated, and bore evident marks of vaccinia; yet he died with the symptoms of confluent small-pox in a very slightly modified form. The immunity afforded by vaccination is nearly or wholly lost by some individuals after the lapse of a certain number of years; but even in such persons confluent small-pox, which is the only form of the disease fatal to those who have been vaccinated, does not present its normal characters. Cases of a second attack of small-pox-a rare occurrence, I repeat- have been recorded by highly trustworthy authors. Diemerbroeck even mentions having seen individuals take the disease three times in three months ; and Borsieri, referring to these cases, quotes others, and among them one celebrated in history, that of Louis XV, who died of confluent small-pox at the age of 74, although he had had the disease when four- teen years old. I have had in my wards a medical student who, though he bore the marks of two attacks of small-pox, took it a third time, and that too in a rather severe form. LECTURE II. VARIOLOUS INOCULATION. Advantages of Inoculation.-Experiments on Clavelization*-Dangers of In- oculation and Means of Diminishing them.-Methods of Inoculating.- The Mother-Pock and its Satellites.- General Symptoms. Gentlemen: Nations dismayed,and physicians intensely occupied with the terrible ravages of small-pox, were in search of some possible means of protection from, or at least of some means of moderating, the scourge. Remedies alleged to be rational, and empirical nostrums seemed equally in vogue; but all prophylactic measures had alike proved failures, when, in 1721, a woman, Lady Mary Wortley Montague, announced to England that she had witnessed a practice at Constantinople which afforded perpetual protection from the disease to all who availed themselves of it. This prac- tice of variolous inoculation, derived from China and Persia, countries in which from time immemorial it had been in common use, as well as in Georgia, Circassia, and Greece, consisted in giving small-pox to persons in health. It was already known by experiment that the prophylaxis of the pestilence was in the pestilence itself; it was known that those who had been once attacked, however mild the symptoms might have been, were henceforth in a condition to traverse small-pox epidemics with impunity, and to expose themselves without risk to the contagion of the disease; it was known that second attacks were exceedingly rare, and altogether ex- * C lavelization is a term derived from clavelee, the French name for ovine variola, popularly known in England as "tag-sore," or "rot," or small-pox of sheep.- Translator. VARIOLOUS INOCULATION. 91 ceptional; but it was also known, on the one hand, that small-pox could not be communicated at pleasure by simple contact; and, on the other hand, that even if it could be communicated in that way, there existed no method of moderating the attacks by subjecting the individual to the contagion of a mild case. Inoculation seemed to offer every desired advantage; while it conferred an almost absolute immunity for the future, it was attended by no danger. Never, it was said, has small-pox proved serious when commu- nicated by inoculation; the disease has always assumed the distinct form, has probably left no trace of its passage, or, at all events, there have been none of those horrible cicatrices to deplore, which so often remain after attacks produced by contagion. The wonderful statements of Lady M. W. Montague, who, when residing at Constantinople in 1717, had not shrunk from having inoculation prac- ticed upon her own son, a boy of six years of age, the new example which she gave, when, on her return to London, she proceeded to have her daughter also submitted to the same treatment, the successful results proclaimed by her, and of which she offered proofs, enlisted the sympathy of a great num- ber of right-minded persons, both among physicians.and in general society. Experiments were speedily set on foot in England, where inoculation was soon adopted, and was ere long generally employed. The new practice (which had many opponents as well as adherents) was carried to America in the same year that it was introduced into England, and three years later it became known in Germany, where some of the children of the first fami- lies of Prussia were inoculated. The practice of inoculation did not obtain a footing in England, America, and Germany, without opposition; but opposition showed itself in France in an inveterate manner. It was abso- lutely prohibited when first proposed in 1723; and it was not till 1756, thirty-three years later, that any one ventured to try it. Although, in France, the movement in its fijvor originated in high places-for those first inoculated were the children of the Duke of Orleans-it was far from being general. Such of you as have a curiosity to know the different phases through which the question of variolous vaccination has passed in our own and foreign countries, ought to read its history as written by Sprengel.* The controversy ended in variolation being accepted and generally prac- ticed till it was dethroned by vaccination ; and perhaps you still know of individuals who were inoculated at the beginning of this century, when, in its turn, the discovery of Jenner was meeting with numerous adversaries. At that epoch, although very advantageously replaced by vaccination, variolous inoculation, which at first had excited so much opposition, had rallied resolute partisans, particularly in England, where, as I have just told you, it was first introduced on its arrival from the East. It was em- ployed in England down to 1841, and to eradicate the practice it was found necessary to pass a stringent act of Parliament. It has now been every- where entirely superseded by vaccination. Circumstances occur, however, in which, for reasons which I will explain to you, one is still obliged to have recourse to inoculation, notwithstanding the palpable inconveniences which it presents. I have found myself placed in such circumstances; and, as it is my duty always to give you an account of my proceedings at the bed of the patient, I have something to say to you on the subject of variolous in- oculation. As I stated when speaking of modified small-pox, I have repeat- edly practiced variolation. I did so for the first time long ago at the Necker * Sprengel : Histoire de la MSdecine; traduite de 1'allemand, par A. J. Jour- dan, tome vi. 92 VARIOLOUS INOCULATION. Hospital, and more recently here, under your observation. But neither at the Necker Hospital nor at the Hotel Dieu have I ever resorted to it, except when vaccine matter was not obtainable, and when a prevailing epidemic of small-pox placed in imminent danger the lives of the young children in our wards. In practicing variolation I have always been anxious-and this is of the highest importance-to place myself as much as I could in the position of the inoculators of former times. Without hampering myself with the pre- cautions which they considered necessary-without preparing, as they sup- posed, the subjects for the operation by their plan (precautionary measures which they themselves soon abandoned, having found them to be useless), I proceeded with a view to communicate the disease in as mild a form as possible. I was struck with a fact which belongs to veterinary medicine. The tag-sore of sheep is a malady identical in its general features with small-pox in the human subject, and the analogy between the two diseases is sufficiently great to enable us to derive from the study of the one practical lessons for the study of the other. Since last century clavelization has been practiced by the most enlight- ened veterinary surgeons and farmers, whenever the disease has begun to prevail, with a view to prevent the ravages of an epizootia. In Bessarabia, where inoculation is still universally practiced, an agriculturist conceived the following plan for obtaining the mildest possible form of ovine variola: he selected a hundred sheep, placed them in a separate park, and then in- oculated them. In nine or ten days the disease declared itself among the animals. The inoculator then took virus from one in which the symptoms were mildest, and with it inoculated a hundred other sheep. He repeated the same proceeding with a third series of a hundred sheep, selecting, as before, the animal in which the symptoms were mildest. The following results were obtained. A considerable number of the first series died, the virus not having lost any of its energy. The disease, however, was less fatal than if it had been produced by ordinary contagion. The sheep of the second series had the eruption in the distinct form, and none of them died. For the third series the distinct character was still more decided than in the second, and in some cases the only eruptive manifestation was the development of a pustule at the point of inoculation. It was then supposed that this last result'could be always obtained. The experimenter had obtained, in point of fact, a preservative virus, which conferred complete immunity, and produced an eruption limited to the mother pustule. Inoculation of aggravated tag-sore, performed on sheep so preserved, afforded absolute proof of the immunity which they had acquired, because-it produced no manifestation. These facts made a great impression upon me, and I asked myself whether the same results would be obtained in human as in ovine variola-whether, by successive series of inoculations in the human subject, an equally great modification of the disease could be produced as had been produced in the sheep, by which the eruption had been limited to a single pustule in the spot where the inoculation had been made. I tried the experiment at the Necker Hospital in conjunction with Dr. Delpech, then my interne, now my colleague as physician to the hospitals and agrege of our Faculty. We obtained the desired result in some children, to the extent that the mother pustule, the master pimple (Ze ma'dre bouton), the pustule of inoculation was alone developed, and that around it there were little pustules, its satellites. If we could be sure of always attaining equally fortunate results, inoculation ought to be the rule, for then it would be attended by no risk, and its con- sequences would be purely beneficial. The inoculation would be equally VAKIOLOUS INOCULATION. 93 without clanger to the person inoculated, and to those with whom he came in contact. This localized variola, without general eruption or serious symptoms, would perhaps be no more contagious than a cow-pock. Unfor- tunately, matters did not turn out so propitiously. In some cases, I attained the complete success of having only the pustule of inoculation ; but in others, in which the very same virus had been em- ployed, there were general eruptions, and, worse still, communication of small-pox to non-inoculated persons. In one case, regarding which I shall have to speak in connection with the subject of regeneration of vaccine virus, the small-pox resumed all its original violence, after having passed through a succession of individuals in a series of inoculations. This result is opposed to those recorded by the inoculators, who made out that the variolous virus becomes progressively milder as the succession of trans- plantations proceeds. The inconveniences of inoculation are on the one hand, the risk of giving dangerous small-pox to an individual, and on the other the dangerous possibility of thus establishing a focus of contagion. It must be admitted that these inconveniences are serious, and they are precisely the inconveniences which, after affording arguments to the adver- saries of inoculation, caused it to be abandoned after the discovery of vac- cination ; they are also inconveniences of such a character as to compel me to discontinue my experiments, and to reserve inoculation for the excep- tional circumstances to which I have already alluded, and of which I shall again speak. It became my duty to renounce inoculation, from the fear that even by inoculating with virus derived from the mildest case, I might cause the death of persons who had neither been vaccinated nor inocu- lated, through their taking the disease in an aggravated form from the individual to whom I had given it. I should have acted otherwise, if it had been possible to isolate the persons inoculated. During an epidemic of small-pox, if I could not obtain vaccine virus, I should not hesitate again to try and to recommend a trial of inoculation, for I should not then feel the responsibility of propagating a disease which was already every- where. There is a small number of persons so constituted as not to take small- pox, though exposed a thousand times to its contagion, and there are also those to whom it cannot be given by inoculation ; but it is more usual to find others who, though more or less insusceptible to the virus, manifest the disease very slowly after inoculation. To take again the example from comparative medicine which I have already mentioned, it happens that when the tag-sore breaks out in a flock of five hundred sheep, it does not attack all the individuals at once, but in succession, so that it rarely occurs that the epizootia has terminated in less than from three to five months. The explanation of this is that some of the sheep, in virtue of a special susceptibility, have at once taken the con- tagion, while others have required several repetitions of contact with it for the production of the same result. The same is observed in small-pox. When, in former times, small-pox prevailed ag an epidemic, attacking the entire population of a locality, hospital, barrack, or prison, it was observed that it showed itself at successive intervals on different sections, although every one had been equally exposed at first to the contagion. In fact, for the production of the disease, there must not only be its cause or morbific germ, but there must also be an economy, a soil, prepared to receive it; a special aptitude of the organism is wanted, without which there can be no conception of the contagion. Inoculation, by forcibly introducing the virus into the economy, without waiting for this aptitude to be developed, finds the subject in that state of unreadiness-the soil is 94 VARIOLOUS INOCULATION. not sufficiently prepared, and consequently the germ does not grow with the vigor which under other circumstances it would have manifested. Moreover, the inoculation can select the germ, that is to say, take the virus in the conditions which are most favorable. By employing matter from a distinct case which has been modified by antecedent vaccination, we attain the greatest probability of communicating a very mild variola, just as the Bessarabian agriculturist acquired by experiment the power of imparting to his sheep a very slight attack of tag-sore. Lastly, inoculation practiced during an epidemic is a preservative against aggravated attacks, protects individuals from contagion, the consequences of which it is impossible to estimate, while, within certain limits, we can estimate the severity of attacks induced by inoculation. It is an excep- tional occurrence for inoculation with virus taken from distinct small-pox to develop the disease in its confluent form. When inoculation was first introduced into Europe, it was more common for it to cause confluent small-pox than afterwards, when vaccinators took the precaution to select their virus under the conditions which I have indicated; and by reading what our predecessors have written on this subject, I have become convinced that inoculation was day by day diminishing in danger, and might have become almost as harmless as vaccination. Inoculation was formerly accomplished by inserting a thread impregnated with variolous matter in a small incision in the skin, the arm being the part generally selected for the operation. Kirkpatrick, in his " Treatise on Inoculation," said that it was sufficient to rub the wound with a bit of linen soaked in variolous matter. He also stated that threads impregnated with the virus, if shut up in well-closed boxes, preserved their power for several months. To prove the great length of time variolous virus preserves its power, Dr. Sunderland, of Barmen, alleges that blankets saturated with the pus of small-pox preserved their contagious properties for more than two years, producing after that interval characteristic pustules on the udders of cows. The blankets referred to were used in his experiments upon the regeneration of cow-pox by communicating small-pox to cows. It was necessary, however, to cover up carefully these blankets with paper, and to keep them in a little cask in a shady, cool place, where the temperature never rose to more than 10° of Reaumur above zero. It is recorded that the Chinese kept the crusts of variolous pustules in porcelain vessels well stopped with wax. They inoculated by introducing into the nostrils tents of charpie covered with the dried matter. At the end of last century, inoculators performed the operation in a manner that was simpler, quicker, and surer than those I have7 just de- scribed ; it consisted in raising the epidermis by means of a lancet, so as to introduce the matter with which the lancet was charged. A prick is suffi- cient. The symptoms which ensue are the following: First of all, there are local phenomena; thus, on the second day after inoculation, there is visible, in the place where the puncture has been made, a small red pimple similar to that which results from vaccination. About the fifth day this pimple has become an acuminated vesicle; it sometimes exhibits in its centre the mark of the puncture, which has a sunken appearance, like an umbilication. On the seventh day the vesicle has become a pustule, and is surrounded by a slightly red areola, which becomes flattened, and assumes a bluish tint. Next day the inflammatory areola increases, and on the ninth and tenth days it increases still more. The pustule, however, continues to grow larger, becomes more depressed in the centre, and assumes more and more the bluish tint; its edges have an uneven, puckered appear- ance : there now arise upon the inflammatory areola a variable number of VARIOLOUS INOCULATION. 95 small pustules, ten, fifteen, or twenty true satellites of the mother-pustule, which at first contain a limpid serosity, and afterwards some watery pus. At the same time the lymphatic glands in the axilla begin to be turgid; this turgidity has attained its maximum on the ninth day, after which it decreases, and about the fourteenth or fifteenth day it disappears. Gener- ally speaking, in thirteen or fourteen times twenty-four hours, the pustule of inoculation has dried up, but there is sometimes formed below it a deep slough, which separates in from twenty to thirty days, leaving a more or less misshapen cicatrix. In general, however, there is no slough, and the crust falls, being succeeded by another, which in its turn also separates; and after a succession of crusts, there js at last a cicatrix larger than that which is left after vaccination. The mother-pustule, which is sometimes found when the disease has been communicated by contagion in the ordinary way, the " master pimple," to use the German expression, presents exactly the same characters as the pustule of inoculation. You have seen an example of this in a man who occupied bed No. 11 ter in St. Agnes's Ward. He was seized when in our wards in June, 1857, with a varioloid affection. Besides tolerably distinct pustules developed on the skin, there was observed, on a level with the nasolabial line, a pustule larger than the others, with a diameter almost equal to that of a twenty-centime silver piece ; it was deeply hollowed out -cutim satis profunde exederat, as Van Swieten said of this kind of pock, which he called the master pokken. A very red areola, as large as a franc piece, surrounded it, and was covered with small vesico-pustular satellites. The patient affirmed that the great pimple had appeared at least twelve days before those on the other parts of the body. On the ninth or tenth day after the operation, the constitutional symp- toms make their appearance. The patient has headache, pains in the loins, vomiting, and, in a word, all the primary symptoms of small-pox. About the eleventh, twelfth, or thirteenth day, the specific eruption is seen, which in general is but slightly confluent, and follows the course of normal or sometimes that of modified small-pox. You have had an opportunity of observing the local and general symptoms of inoculated small-pox in an infant, upon whom I deemed it right to practice inoculation at a time when the nurses of our wards were being carried off by an epidemic, and when we had no vaccine virus. This infant, aged twenty-four days, suckled by its mother, was inoculated by means of a puncture on the right arm, with variolous matter taken from a pustule at the eleventh day of the disease, in a case of modified distinct small-pox. An unsuccessful attempt to inoculate this infant had been pre- viously made with matter from an exceedingly distinct varioloid case. The result of the second operation was to produce on the fourth day a small umbilicated pustule, which, following a regular course, left, on the twenty-first day after its first appearance, a very deep slough. On the eleventh day after inoculation, the seventh from the appearance of the mother-pustule, the infant had the disease in its distinct form, and without any serious constitutional symptoms. The pustules dried up on the seventh day from the setting in of the primary symptoms, such as vomiting and diarrhoea, which began on the ninth day from inoculation. The little patient recovered rapidly, and thenceforth he was safe from small-pox, and even unsusceptible to vaccination. Indeed, on the eighteenth day, we tried in vain to affect him with the vaccine virus, and twenty-five days later we inoculated him with matter from a case of confluent small-pox, which did not even produce the pustule of inoculation. Notwithstanding the complete success of this experiment-a success such as I had formerly 96 COW-POX. obtained elsewhere-I felt that it was my duty to discontinue inoculation, as we had obtained a supply of vaccine virus, and the epidemic of small- pox seemed as if it were on the wane. LECTURE III. COW-POX. Grease of Horses.- Cow-pox in the Cow.- Cow-pox in the Human Subject.- Cow-pox and Horse-pox are Analogous to, but not Identical with, Small- pox: Practical Importance of this Distinction.-Regeneration of Cow- pox. Gentlemen*: Soon after the middle of last century, when the practice of inoculation had become general in England, a belief prevailed in certain counties that persons' who contracted cow-pox from cows were permanently protected from small-pox, whether exposed to its contagion, or inoculated with its virus. Jenner, the inoculator of the district in which he resided, was not unacquainted with this popular tradition. At first he did not believe in it; but he soon became convinced of its truth, having ascertained, upon reliable evidence, that several persons who had twenty-five, thirty, and fifty years previously contracted cow-pox in the dairies of the country had, from the date of that occurrence, escaped small-pox. He was thus led to inquire into the conditions under which cow-pox became developed in the human subject, and to entertain the idea of inoculating with it. His experiments led to results identical with those produced by direct contagion, for the persons to whom he communicated cow-pox remained as insusceptible to variolous influence as those who had had natural small-pox. Far be it from me to argue that Jenner was not the discoverer of vacci- nation ; for even though he should not be accepted as the first who commu- nicated cow-pox to man by inoculation, there would be nothing to subtract from his glory, since it appears probable that he did not know of the experiments which Benjamin Jesty made in his family. Although there may be involved in this history a question of priority, Jenner had the incontestable merit of having contended against all the obstacles put hi the way of the practice of vaccination, and of having communicated to con- temporary physicians the belief which he had deduced from the observation and rigorous interpretation of facts. Respect, however, for historical verity makes it incumbent upon me to lay before you various documents lately translated in the Gazette Medicale de Lyon, from the Lancet, of London, and which seem to prove that Ben- jamin Jesty, a Gloucestershire farmer, was the first to inoculate with cow- pox, he having, in 1774, performed the operation upon his wife and two sons, for the purpose of protecting them from small-pox. The same periodical publishes a note from Mr. John Webb, showing that small-pox may be communicated from man to the cow, and that persons contracting the disease modified by this transmission are proof against vari- olous contagion, Allow me to translate to you John Webb's narrative, a letter from Mr. Alfred Haviland, surgeon, regarding Benjamin Jesty's dis- COW -POX. 97 covery of cow-pox, and also an extract, on the same subject, from the records of the Vaccine Institution. First, then, I will now read to you the narrative of John Webb, which was found among his manuscripts after his death, and is dated in the year 1799. This document was communicated to the Lancet by his grandson, Thomas Watts, and is to the following effect: "Some time in the month of May, 1792, having twenty-four children col- lected together at a house in Doynton for the purpose of being inoculated, and a Betty Bowman, then aged 80, accidentally coming in, she was asked by another woman present whether she had ever had the small-pox; to which Betty replied in the negative, asserting, with a considerable degree of confidence, that she was certain she never should, having in her younger days caught the cow-pox from a cow that was infected by a man in the small-pox. Such an opinion naturally induced me to desire of her a more particular account of the circumstance, when I was informed that, when she was twenty-three or twenty-four years old, she lived in the service of a farmer, on whose estate, at a distance from the farmhouse, or any other habi- tation, there was a small cottage, together with some cowsheds; that the cot- tage was let to a man (probably one of his laborers) who dying in the small- pox some time betwixt Michaelmas and Christmas, the bed and bed-mat on which he had lain were thrown out into the sheds; that a cow belonging to their dairy being, as she termed, very chilly, frequently went into the cow- shed, and had been observed to lie down on or near the bed and mat; that shortly after the same cow was seized with the cow-pox, and the whole dairy, consisting of nine cows, sickened one after the other, till at length the milk was so bad that it could not be used, and of course the cows were suffered to go dry, till which time she constantly assisted in milking them ; that soon after she was seized with rigors and pains in her limbs, had a tumor form in the right leg and axilla, and that three pustules appeared on the hand near the thumb, from which there was a discharge for some time (she be- lieved about nine days) ; that, as before mentioned, she neither prior nor subsequent to that period had the small-pox, though she had frequently visited persons ill in it, and once, in particular, lay on a bed on which a person had died in that disease, the bed-clothes only being changed. She likewise observed that two or three persons who had had the small-pox were frequently among the cows, but received fio infection. She likewise informed me that she knew a Mary Hathaway, who milked infected cows at one time, and was not infected by them, but that at another time she was; that she likewise never had the small-pox prior or subsequent to that period, though she resided several years in Bristol."* As a, sequel ,to the narrative now quoted, the Lancet gives the following statement, by Mr. Alfred Haviland, Surgeon to the Infirmary of Bridge- water. It refers to Mr. Benjamin Jesty, "the proto-martyr of vaccination:" "At the Rose and Crown Inn, Nether-Stowey, county of Somerset, my attention was drawn, on the 31st of May last, to a photograph taken from a large portrait of a good specimen of the fine old English yeoman, dressed in knee breeches, extensive double-breasted waistcoat, and no small amount of broadcloth. He was represented sitting in an easy chair, under the shelter of some wide-spreading tree, with his stick and broad-brimmed hat in his left hand, his ample frame was surmounted by a remarkably good head, with a countenance which at once betokened firmness and superior intelligence." VOL. I.-7 * Lancet: 13th September, 186'2, p. 291. London. 98 COW-POX. " I have been thus particular in describing the portrait, for I am not quite certain whether the photograph was taken from a drawing, an engrav- ing, or an oil-painting; if, however, the source was an engraving, in all probability there are some copies still extant, which the curious in such matters may think worth collecting. On the back of this photograph is a copy of the epitaph on our subject, as follows: ' Sacred to the memory of Benjamin Jesty, who departed this life on the 16th April, 1816, aged 79 years. He was born at Yetminster, in this county, and was an upright, honest man, particularly noticed for having been the first person (known) who introduced cotv-pox by inoculation; and who, from his great strength of mind, made an experiment from the cow on his wife and two sons, in the year 1774.' (From the tomb in the churchyard at Yetminster, Dorset.) " I am informed by his relative, Mrs. William May (nee Jesty), that when the fact became known that he had vaccinated his wife and sons, his friends and neighbors, who had hitherto looked up to hirti with respect on account of his superior intelligence and honorable character, began to regard him as an inhuman brute, who could dare to practice experiments on his family, the sequel of which would be, as they thought, their meta- morphosis into horned beasts. Consequently, the worthy farmer was hooted at, reviled, and pelted .whenever he attended the markets in his neighbor- hood. He remained, however, undaunted, and never failed from this cause to attend to his duties; and the secret of this bold conduct may be traced in his determined chin and nose and firm lips. After living to see another enriched and immortalized for carrying out the same principles for which he had been stoned thirty years before, he died of apoplexy, like Jenner, in 1816. Jesty's experiment on his family was performed in 1774; and Jenner's on the IMh of May, YIM, just twenty-two years later."* Dr. H. P. Davis,, of London, having received from one of Benjamin Jesty's grandsons a copy of the following document, indited and signed by the medical officers of the Original Vaccine-Pock Institution, sent it to the Lancet. ''Mr. Benjamin Jesty, farmer, of Downshay, in the Isle of Purbeck, having, agreeably to an invitation from the medical establishment of the Original Vaccine-Pock Institution, Broad Street, Golden Square, visited Loudon in August, 1805, to communicate certain facts relating to the cow- pox inoculation, we think*it a matter of justice to himself, and beneficial to the public, to attest that, among other facts, he has afforded decisive evidence of his having vaccinated his wife and two sons-Robert and Ben- jamin-in the year 1774, who were thereby rendered unsusceptible of the small-pox, as appears from the exposure of all the parties to that disease frequently during the course of thirty-one years; and from the inoculation of the two sons for the small-pox fifteen years ago. That he was led to undertake this novel practice in 1774, to counteract the small-pox at that time prevalent where he then resided, from knowing the common opinion of the county ever since he was a boy, now about sixty years ago, that persons who had gone through the cow-pox naturally, that is, by taking it from cows, were unsusceptible of small-pox; by himself being incapable of taking the small-pox ; by having gone through the cow-pox many years before ; from having personally known many individuals who, after the cow- pox, could not have the small-pox excited ; from believing that the cow-pox was an affection free from danger; and from his opinion that by the cow- pox inoculation he should avoid ingrafting various diseases of the human * Lancet: 13th September, 1862. London. COW-POX. 99 constitution, such as the evil, madness, lues, and many other bad humors, as he called them." " The remarkably vigorous health of Mr. Jesty, his wife and two sons, now thirty-one years subsequent to the cow-pock, and his own healthy appearance at the time (seventy years of age), afford a singular proof of the harmlessness of that affection. But the public must with particular interest hear that during their late visit to town Mr. Robert Jesty very willingly submitted publicly to inoculation for the small-pox in the most vigorous manner, and that Mr. Jesty also was subjected to the trial of in- oculation for the cow-pock after the most efficacious mode, without either of them being infected." "The circumstances on which Mr. Jesty purposely instituted the vaccine- pock inoculation in his own family, viz., without any precedent, but merely from reasoning upon the nature of the affliction among cows, and from knowing its effects in the casual way among men, his exemption from the prevailing popular prejudices, and his disregard of the clamorous reproaches of his neighbors, in our opinion well entitle him to the respect of the public for his superior strength of mind. But further, his conduct in again fur- nishing such decisive proofs of the permanent anti-variolous efficacy of the cow-pock, on the present discontented state of many families, by submitting to inoculation, justly claims at least the gratitude of the country." " As a testimony of our personal regard, and to commemorate so extra- ordinary a fact as that of preventing small-pox by inoculation for the cow- pock thirty-one years ago, at our request, a three-quarter-length picture of Mr. Jesty is painted by that excellent artist Mr. Sharp, to be preserved at the original Vaccine-Pock Institution." "G. Pearson, L. Nikol, Thos. Nelson, Physicians. - Wiieate, F. Forster, Consulting Surgeons. J. C. Carpue, J. Doralt, Surgeons. F. Rivers, E. A. Brand e, P. De Bruge, Visiting Apothecaries. J. Heaviside, T. Payne, Treasurers."* Gentlemen, however long you may think these details, you will, in con- sideration of the interest which they present, pardon me for having laid them before you. I repeat, however, that if Jenner was not the first to inoculate with cow-pox, his was no less the honor of having established the practice of vaccination. Jenner, in his first publication, which appeared in 1798, while he avoided affirming in too absolute a manner that cow-pox was a complete preserva- tion against small-pox, showed anxiety to make known the nature of his discovery. Experiments, repeated first by Pearson, were afterwards under- taken on a great scale by Woodville, Physician to the London Inoculation Hospital, and ere long the testimony of these physicians, along with that of very many others, was given in favor of Jenner's discovery. Vaccina- tion, in spite of the opposition it encountered, in spite of the violent and unjust attacks to which it was subjected, in spite of the most obstinate resistance and the most absurd prejudices with which it had to contend even in England, soon came to be generally employed. The favorable reception which it immediately received in Hanover extended to the rest of Germany, and almost simultaneously, to France, where the Duke of * Lancet, 25th October, 1862, p. 461. London. The documents in the text are reprinted from the Lancet; and are not translations from the French.-Trans- lator. 100 COW-POX. Rochefoucault-Liancourt, who during his residence in Great Britain had seen its success, forcibly called the attention of government and the public to this important subject. Cow-pox, that singular malady derived by man from the cow, and then transmitted with wonderful facility from person to person, had ceased to be thought of in relation to its source, and had, so to speak, become forgotten. In the years immediately subsequent to the discovery of vaccination, picote* is so seldom mentioned by authors, that one may be led to believe that cases of it were then rare, that it occurred seldom, at long intervals only, and in privileged places. In England it had nearly ceased to be a topic of discussion, when, in 1812, attention was called to several cases in the neighborhood of Berlin. In 1816, it was met with several times in the Duchy of Brunswick. At a later period, however, the occurrence of small- pox in persons who had been vaccinated having suggested the idea that the vaccine virus had degenerated, it was deemed necessary to go back to the fountain-head, or, in other words, to search for cow-pox in the cow. The investigation began in Germany, where, at the commencement of the in- quiry, it was established that the picote of cows was by no means so rare as might be inferred from the long silence which had existed regarding it. In Holstein, irrespective of isolated cases, it had prevailed as an epizootia five times in eleven years. The attention of Government having been awakened, orders were issued in 1826, 1829, 1830, and 1831, to search for vaccine matter in the cow. Prizes were offered to the proprietors of cows affected with the disease, and from that time cases multiplied in Wiirtem- berg and the Duchy of Baden. In 1836 a commission was appointed by the Academy of Medicine of tParis, to examine into a case at Passy, near Paris. A lady of the name of Fleury, residing at Passy, having stated to Dr. Perdreau, of jChaillot, that her cow, affected with picote, had communicated the affection to her hand, MM. Bousquet, Emery, and Gerardin, were commissioned to study the case ; and the result was that they obtained characteristic cow-pox by inoculating the arm of a child with matter taken from Madame Fleurv's hand.f When these inquiries were going on in Europe, Dr. Macpherson, in 1833, published his experiments on vaccination, and announced that he had seen in the neighborhood of Calcutta, in India, an epizootia of tag-sore. He found that this affection could not only be communicated by inoculation from cow to cow, but also from the cow to man, and afterwards from man to man. Observers were struck with the remarkable fact that transmission took place more readily when the virus was humanized, or, in other words, when it had been transmitted from man to man. The action was more powerful than that produced by inoculating the human subject direct from the cow. Dr. Steinbrenner has recorded a remarkable example of this peculiarity, which I shall now quote exactly from his Treatise on Vacci- nation. " On the 18th May, 1845, a proprietor informed me that one of his cows had an eruption on the udder and teats. Upon examining the cow, * The word picote in the text evidently refers to the vaccine disease in the cow, but in some districts of France, picote is the current name of small-pox in the human subject; and wherever French is spoken, a man marked with small-pox is said to be picote-Translator. t Sur le Cow-pox decouvert a Passy pres Paris, le 22 Mars, 1836.-Memoires de I'Acad&mie de Mede cine, t. v, p. 600. COW-POX. 101 and comparing what I saw with the descriptions of authors, I became nearly certain that I had at last found jncote; and although the eruption was too far advanced to justify the hope of obtaining very efficacious virus, I lost no time in collecting a considerable quantity on four plates of glass. About an hour afterwards I inoculated, by sixteen punctures, two unvac- cinated children. Only one of the sixteen punctures produced a vaccinal pustule; but it was a very beautiful and large one, which passed through the different stages in the most perfectly regular manner. On the eighth day, two children were vaccinated from this pustule, the virus being trans- ferred direct from arm to arm ; and this time the sixteen inoculatory punc- tures produced sixteen beautiful vaccinal pustules. Since that occurrence I have only vaccinated with lymph derived from that source, and have obtained precisely similar results. I sent supplies of lymph taken from my first cases to the Academy of Medicine of Paris, through M. Bousquet; to the Medical Society of Strasburg; and to many brother physicians, particu- larly to the cantonal physician of Saar-Union; and to Drs. Fodere, Kuntz, Clausing, Ac. Everywhere it produced a very beautiful vaccine pock, yielding lymph, which was at once substituted for that formally in use."* Similar results have been more recently obtained by physicians and veterinary practitioners in the department of Eure-et-Loir, by whom cow- pox in the cow was also found. Similar results are observed in the vacci- nations-particularly in the revaccinations-now taking place in our hos- pitals, with vaccinal lymph derived from the heifers of Dr. Lanoix. That lymph gives rise to vaccinal pustules much less frequently than that taken from the arm of a child. With reference to this point, I would remark, that the lymph obtained from the heifers of Dr. Lanoix is not primitive lymph, and therefore is not more active than that taken from the human subject; and, moreover, it is the virus of cow-pox modified and weakened by a considerable series of successive generations. It appears to me that it has lost much of its power in passing successively from heifer to heifer. Whatever theory we adopt, the fact remains, that vaccine lymph taken direct from the heifers referred to is less active than that which has been taken from man-than that which has been humanized. I must not allow this opportunity to escape without explaining to you the characteristics of cow-pox in the cow ; as it is of the greatest impor- tance for physicians, especially for those practicing in country places, where the supply of vaccine lymph may fail, to be able to recognize the affection. The eruption consists in pustules on the udder and teats of the affected animal, having a great resemblance to those which we lately saw on the face of a small-pox patient who lay in bed No. 11 ter of St. Agnes's Ward, whose case I have already brought under your notice, as presenting a remarkable example of the inoculation-pustule. The cow-pox pustules are at first pimples, varying in size from that of a lentil to that of a common round bean. They become more and more elevated : on the second or third day from their first appearance, they acquire a pustular character, are filled with a colorless lymph, and are depressed in the centre. Toward their centre, these pustules are of a bluish-white, livid color, and towards their periphery, where an areola has already formed, they are reddish or yellowish-white ; they then resemble the pustules produced by variolous inoculation. In other cases, they are of a silvery hue, of a pale red, a reddish yellow, or a clear yellow. This difference in the color of the pus- tules is dependent upon their degree of development, and also, to a certain extent, upon the natural tint of the udder. On the following days they * Steinbrenner : Traite de la Vaccine, p. 534, 102 COW-POX. become larger, and often attain the size of a half-franc piece; and in these rare cases they are also more numerous, the udder and teats sometimes presenting from eight to twenty pustules, which reach their maximum development on the ninth or tenth day ; at this period also, the areola which, since the formation of the pustule, has formed a narrow ring, becomes more extended, but in cows with brown or black udders the areola is scarcely visible. Hardness, swelling, increased heat of skin, and sometimes very great tenderness, are then perceptible. There is at the same time an exacerbation of the general symptoms, such as distaste for food, restlessness, and fever. The milk both deteriorates in quality and dimin- ishes in quantity, and its secretion is altogether arrested when the eruption is very abundant, and accompanied by an excess of reaction. Immedi- ately after the ninth day, crusts form in the centre of the pustules, while at their the lymph grows thicker and thicker, till at last it becomes converted into a cheesy pus. The crusts, if not previously torn off, fall between the eighteenth and twenty-fourth day, leaving in their place ulcer- ations, which in some cases eat so deeply into the tissues as to detach the teats. In other cases, inflammatory swellings and abscesses of the mamma supervene, which continue for three or four months. As I have broached the history of cow-pox, allow me, gentlemen, to say a few words upon questions connected with that subject. First of all: What is the origin of cow-pox ? Considering the immunity from small-pox which cow-pox confers on the human race, it has been asked whether cow- pox is not in point of fact human small-pox modified by transmission to the cow, just as cow-pox is modified by transmission from the cow to man ? It has also been asked whether cow-pox is not a distinct disease, peculiar to the animals in which it is observed ? And, finally, it has been asked, whether it does not originate in a disease peculiar to other kinds of animals, and which is not small-pox? Jenner, adopting the opinion generally received in his own country, re- garded cow-pox as originating in a disease peculiar to horses termed grease in England and eaux aux jambes in France. The illustrious discoverer of vaccination had remarked a fact, well-known also to the farmers and peas- antry, that cow-pox was met with only in the dairies where the cows were attended to and fed by men who likewise had charge of horses. Whenever grease was observed in stables, cow-pox soon showed itself in the cow-houses, whither it was brought by the men-servants of the farm who came to milk the cows with hands soiled by pus from horses affected with grease. In dairies, where women only were employed, as in Ireland, cow-pox was very rare. Although the proposition of Jenner cannot be accepted as absolute, experiments have proved that there is an analogy between, if not an identity in, the two maladies. It is one thing, however, to admit that grease may be transmitted from the horse to the cow, and then produce true cow-pox, and another to maintain that the only source of cow-pox in cows is grease in horses. A recent case has once more demonstrated the identity of the two dis- eases. Early in March, 1856, Dr. Pichot of La Loupe, a physician of the department of Eure-et-Loir, was consulted professionally by a farrier's as- sistant ; this individual had on the back of both hands pustules which were opaline, confluent, of about a centimetre in diameter, and depressed in the centre, where a small linear crust was visible. They had exactly the ap- pearance of vaccinal pustules of the eighth or ninth day. The man, who had never been vaccinated, affirmed that he had not been in contact with a diseased cow, but he recollected that twenty-four days previously he had shod a horse affected with grease. The horse in question belonged to a COW-POX. 103 farmer. The veterinary practitioner at La Loupe, a distinguished pupil of the schools of Alfort and Toulouse, verified the disease, which still existed when he examined the horse. Dr. Pichot immediately collected, between glass plates, fluid from the pustules, and sent some of it to Dr. Maunoury of Chartres. Without waiting to hear the result of Dr. Maunoury's experiments, Dr. Pichot tried to vaccinate his patient. The operation produced no charac- teristic effect, although the lymph used was taken from the arm of a child, from which at the same time two other children were vaccinated, in both of whom the true vaccinal pock appeared. There were visible on the sixth day from the operation, in the situation of the six punctures made on the man's arm, only two small rounded pustules, which were partially covered with a crust, and bore no resemblance to the pustules on the arms of the children. An attempt was made to inoculate another child with liquid from these two pustules; but on the eighth day no result whatever had taken place. On that day, the same child was vaccinated with ordinary vaccine lymph, and in seven days he exhibited four superb vaccine pocks, from which three other children were successfully vaccinated.. Dr. Maunoury inoculated a child with the matter sent to him by Dr. Pichot, making five punctures, viz., three on the right and two on the left arm. The result was the appearance on the eighth day, on the right arm, of one beautiful clear pock, as large as a lentil, filled with yellowish serosity and surrounded by a reddish circle of about a centimetre in diameter. Dr. Maunoury vaccinated several subjects from this pustule. Three children were inoculated with pus taken from it, and all three were found to be per- fectly vaccinated. A fifth child was vaccinated with lymph taken from one of the three, and the lymph in this its third generation was proved to be efficacious; it was found to be equally efficacious in a fourth and fifth generation. It is evident, therefore, that it was true vaccine matter which was communicated to the first patient by the horse affected with grease which he had shod. In this history, accordingly, we find a confirmation of Jenner's opinion. Jenner, however, notwithstanding the soundness of his theory, was never able to produce more than a simple inflammation in those whom he inocu- lated with matter taken from horses affected with grease; but then it must be remembered, that he always used pus from the old ulcerations, and never the clear lymph of the recent pock. After his time, the same facts, confirmed at a later period by Drs. Pichot and Maunoury, were irrefragably estab- lished by experimentalists. In 1801, Dr. Loy published an account of his experiments on the origin of cow-pox, in which he mentioned that he had inoculated men as well as cows with matter taken from horses affected with grease. Dr. Loy having observed on the hands of two persons, a farrier and a butcher residing in Yorkshire, a pustular eruption much resembling cow-pox and accompanied with great constitutional disturbance, inquired into the circumstances and found that one of these individuals, for some time previously, had had charge of horses suffering from grease. He took lymph from this person and with it inoculated his brother and another child; in both cases this inoculation produced pustules exactly similar to those of true cow-pox, both in respect of their appearance and the course they ran. With the same lymph with which he inoculated the two children, he inoculated a cow, producing thereby a very beautiful cow-pock, which was accompanied by all the accessory phenomena. From that pock he in- oculated a child in whom, in due course, a beautiful cow-pock appeared ; this child was ascertained to be proof against small-pox, for on the sixth day after the vaccinal inoculation, variolous inoculation was performed without causing any subsequent result. It will be seen that the observa- 104 COW-POX. tions of Dr. Loy bear a great analogy to those made at a later date by Drs. Pichot and Maunoury. But, at first, Dr. Loy failed in his attempts to inoculate cows with matter taken from horses affected with grease. He repeated his experiments several times without success, using matter taken from other horses; he was also at first equally unsuccessful in his attempts to inoculate man from the horse. At last, he succeeded in finding a horse in which the grease had existed for only fifteen days; the cases from which till then he had obtained his matter were of older standing. With matter derived from this recent case, he inoculated five cows, and in all of them cow-pox was the result. From these cows he obtained lymph with which he produced cow-pox in children, whom he subsequently found to be proof against vario- lous inoculation.* Sacco, of Naples, who had at first unsuccessfully inoculated twenty-seven cows and eight children with lymph taken from grease in horses, observed pustules on the hands of persons who had charge of horses affected with the disease; with fluid from these pustules, he inoculated nine children and one cow; in two of the children he produced normal cow-pox, a result ex- actly similar to that formerly noticed as having been obtained by the phy- sicians of the department of Eure-et-Loir. Finally, in 1805, Viborg, a Danish veterinary practitioner, inoculated the udders of cows with grease-matter, taken from horses, and after several failures obtained the desired result, viz., a characteristic, well-developed eruption of cow-pox on the fifth and sixth days after inoculation. Other observers, among whom may be mentioned Professor Ritter, of Kiel, have reported cases of cow-pox following inoculation with grease-matter, and yielding a perfectly efficacious vaccine lymph. To these statements I may add facts observed in the spring of 1860, by MM. Sarrans, of Rieumes, and Lafosse, of Toulouse. During an e'pizootia among horses, a man was attacked with swelling of the hamstrings, whence issued a sanious discharge. M. Lafosse charged a lancet with this exuda- tion, and then therewith inoculated in succession two young cows; in both, pustules appeared, presenting all the characters of cow-pox. With matter taken from these pustules he reproduced vaccine lymph, with all its char- acteristics and properties. Hitherto I have spoken of grease [eaux aux jambes], employing a term in common use; but, in point of fact, observers have not yet made out the exact nature of the disease of the horse, which, when transmitted to the cow by inoculation, gives rise to cow-pox. In a discussion at the Academy of Medicine,f and afterwards at the Biological Society in 1861, Mr. H. Bouley pointed out at great length that veterinaries were much divided in opinion as to the exact nature of the disease which goes by the name of eaux aux jambes. M. Leblanc, who went to Toulouse to study the disease in the mare which had supplied M. Lafosse with new vaccine lymph, proved that this mare had not the disease called eaux aux jambes, but all the veterinaries who observed the epizootia at Rieumes were agreed that it presented all the characters of an epidemic eruptive fever. It is not within my province to give a name to a disease of horses which has already received a name from veterinary physicians. Can we, looking at it as an eruptive fever, compare it with the tag-sore [clavelee] of sheep? Can there exist in the horse an eruptive fever, which, when communicated to man by direct or indirect * Steinbrenner op. cit., p 608; and Loy's Account of some Experiments on the Origin of Cow-pox. 8vo. Whitby, 1801. f Bulletin de de Medecine, 1861-62, t. xxvii, p. 854-880. COW -POX. 105 inoculation, yields a virus which either is vaccine virus or is analogous to it in its properties? These are questions which we may at present ask, but it will only be in the future that they can be answered. Alongside of the experiments conclusively in favor of the transmission of the disease from horses to the cow and human species, others of an opposite tendency are cited. In France attempts, made at Alfort and Rambouillet, to inoculate cows with cow-pox, by using grease-matter, were not till recently attended with success, but then inoculation of children with matter from the horse disease was not tried. In explanation of these negative results, it has been urged that possibly the cows which resisted the inoculation by grease-matter from horses had had cow-pox at some former period; and also that the malady is not inoculable at all its stages, and that it cannot be communicated by punctures made anywhere. Finally, as was alleged by Dr. Loy, there are evidently several different diseases which have been confounded together under the name of grease, only one of which is the true disease capable of being transmitted to the cow, and transformed in the cow into cow-pox, and in the human subject into vaccinia. The re- searches of M. II. Bouley have corroborated this opinion of Dr. Loy. Jenner does not seem to have been acquainted in an exact manner with the disease of horses which, when transmitted to cows, produced cow-pox; he gave it the vague name of "sore heels," which means disease of the heels. To the "sore heels" of Jenner, the "javart" of Sacco, the "affection furonculeuse" of Hertwig, the "maladie pustuleuse" of M. Lafosse-all of which it has been said, and of some of which it has been demonstrated, that they produce cow-pox by inoculation-to these affections M. II. Bouley has. just added aphthous stomatitis. M. Depaul, however, has shown that what was sup- posed to be merely an aphthous affection of the mouth was a general pus- tular eruption very analogous to small-pox. In other words, it was horse- pox, the malady which gives cow-pox to cows. But the distinctive characters of horse-pox have not as yet been accurately determined, and it is still a disease without an historian. There are numerous examples in human pathology of inoculable diseases not inoculable at all their stages, and also of diseases which can be set up more easily by introducing the virus at one part of the body than at another. We know that syphilis can be easily introduced into the system by making a puncture, and inoculating with pus taken from a chancre; and we also know that generally syphilis cannot be inoculated by using matter from a pustule or muculent scab of ecthyma syphilitica. Some physicians, wrongly, however, deny that it is ever possible to effect this last-mentioned kind of inoculation. It is now beyond dispute that, in certain exceptional circum- stances, syphilis can be inoculated from secondary forms of the disease. When we return to this question in treating of syphilis in new-born children, we shall see that the disease is transmitted from infant to nurse only under very special conditions. These conditions chiefly consist in frequent and long-continued contact of the syphilitic virus of the affected parts of the infant with the absorbing surface in the nurse. They are most favorable when the infant sucks with power and energy, and when the nipple is in a state of continuous and in- creasing erection from the time that it is touched by the lips of the infant. The excitation of the nipple imparts to it an anatomical and physiological state, in virtue of which the skin covering it, in obedience to the laws of endosmosis, opens a door for the absorption of the contagium, so that there is required neither denuded surface, excoriation, nor fissure of the nipple, the more usual way by which syphilis enters the system of the nurse from that of the nursling. If, then, we compare what takes place in respect of 106 COW -POX. the transmission of syphilis and grease in their more advanced forms, we can understand the unsuccessful attempts which have been made to inoculate the latter, and can explain the negative experiments made at Alfort and Rambouillet, as well as other negative experiments, by supposing that the virus was taken at a period when it had lost its energy through the too great length of time which had elapsed since the primary development of the disease. Is it possible otherwise to explain the positive results obtained by learned and conscientious observers, such as Loy, Sacco, Viborg, Ritter, Berndt, Pichot, and Maunoury? From this brief statement of facts, I conclude with Steinbrenner, whose opinion is also that of Woodville, Coleman, Viborg, Sacco, and others, that cow-pox may originate in grease: but here I must repeat a proposition I have already carefully established, that this is not equivalent to saying that cow-pox has an exclusive origin in inoculation or in contact with the disease of horses: indeed, cow-pox generally arises quite independently of grease. Although grease is undoubtedly transmissible from horse to cow and from horse to man, it loses much of its likeness to itself by transmission: and cow-pox in the cow has not a greater resemblance to grease than vaccinia (or humanized cow-pox) has to cow-pox in the cow. These modifications in the form of affections, which are essentially and fundamentally identical, depend on the nature of the organisms in which they are developed; and similar modifications are not rare in comparative pathology. For example, qialignant carbuncle [sang de rate], a disease peculiar to the ovine species, becomes quarter-evil [charbon] in horned cattle, and ma- lignant pustule [pustule maligne] in man. This typhic, strange, general disease, frequently destroys a great number of wool-clad animals in certain countries of Europe, particularly in the departments of France which constitute the old provinces of Beauce, Berry, and Brie. It can be transmitted to sheep, by inoculating them with the blood of an infected sheep. If a little blood, taken from the spleen imme- diately after the animal has been killed and before putrefaction has begun, be introduced by inoculation into the ear, groin, or inguinal region of another sheep, there is no indication of any effect' having been produced, till from twenty-six to thirty-six hours have elapsed : the animal then, all at once, loses appetite, shows typhic symptoms and, within an hour or two, dies. On dissection, lesions similar to those found in the sheep from which the blood used for the inoculation was taken are observed. On inoculating with blood taken from the second sheep a third in a district far away from that of the other two, the malady is communicated ; and it can in succession be similarly transmitted to individuals of the same species, the disease always remaining the same, and identical in its symptoms. If, however, you inoculate an ox or a cow with blood from the spleen of an infected sheep, you no longer produce the ovine malignant carbuncle [sang de rate], but a kind of charbon which, though at first only a local affection, will soon become a general disease attended by grave symptoms, quickly proving fatal, unless it be eradicated in its original site by energetic cauterization. Again: A shepherd, when skinning a sheep which had died from sang de rate, was inoculated with the disease, either by his excoriated hands having been soiled with the animal's blood, or by his hands, perhaps quite free from excoriations, having remained too long in contact with its hide. After a certain time, a disease of special character was developed in this man : which, although sang de rate is from the onset a general malady, was at first exclusively local: it was the affection called malignant pustule. This malignant pustule, which is really a small vesicle, occasions tingling COW - POX. 107 in the skin for a day or two, soon followed by a feeling of numbness extend- ing along the arm, if the pustule is situated on the hand or forearm: soon after this there appears in the centre of the little vesicle a gangrenous speck, which resists the point of the bistoury, while at the same time general dis- turbance of the system supervenes, and the patients sink under ataxo-ady- namic symptoms, lasting sometimes for five or six days. Malignant pustide is at first so purely a local affection that its constitutional development may be prevented, and the patients saved by adopting the treatment now gener- ally followed in Beauce, which consists in vigorous cauterization, effected more particularly by applying corrosive sublimate to the parts previously deeply scarified. The physicians of the department of Eure-et-Loir, as well as those of Perche and Berry, are well acquainted with this treatment, and when called in to a case promptly, that is to say, sufficiently early to cut short the progress of the disease, they have little anxiety abouf the issue. I am myself in a position to form an opinion on this question. In 18t56 one of my country servants contracted the disease when handling three sheep which had died of the sang de rate. One Sunday, just as I came home, this man showed me his hand, on which I saw a very characteristic malignant pustule: the beginning of the malady dated back to the previous Wednes- day: there was already some feverishness and general constitutional dis- turbance. I scarified the affected part, and introduced corrosive sublimate into the wound: in forty-eight hours the cure was ascertained: on the fol- lowing Sunday I found my patient in perfect health, excepting that he had a painful scab on his hand. When we see a disease undergo such remarkable mutations by trans- mission from an animal of one species to an animal of another species; when we see different organisms respond in so different a manner to the same morbific cause, it ought not to be looked on as astonishing that grease should also change its form when transmitted to the human subject or the cow; nor need it any more be considered wonderful that there is so little resemblance between cow-pox in the cow and vaccinia, although the nature of both is the same. We can in the same way understand how the further question may be asked-whether cow-pox is anything else than human small-pox modified by development in the organism of the cow, so as to lose its original qualities, and be re-transmissible to man with its behavior wholly changed. Let us pause a moment to consider what has been done to elucidate this question, so full of interest. Many attempts had been made to produce cow-pox in cows by inoculat- ing them with virus of small-pox from the human subject, but without causing anything like cow-pox, although the experiments were made in various ways, and upon animals of different ages, till 1807, when Dr. Gassner, of Gunzburg, announced that he had obtained the desired result. He inoculated eleven cows with small-pox virus, and obtained true cow-pox from them, with the matter of which he inoculated children in whom real vaccinia was thereby produced. These results were called in question; but in 1839 Dr. ThielS, of Kasan, having repeated the experiments of Gassner, stated, that after having tried ineffectually to inoculate the cow both with vaccine lymph and small-pox matter from man, he at last suc- ceeded with the latter, cow-pox pustules being produced in the cow : with matter taken from these pustules, he obtained normal vaccinia in children. These experiments date back to 1836, from which time Dr. Thiele con- tinued to vaccinate with the same lymph ; and when he wrote, it had passed through seventy-five generations, and had demonstrated its efficacy in more than 3000 persons. More recently, to put this efficacy to the test, he in- oculated with small-pox twenty-one of those he had vaccinated, and without 108 COW-POX. causing small-pox in any of them. The cows upon which Dr. Thiele made his experiments were between four and six years old, newly calved, and were, as often as he could find them, cows with white teats. He confined them to their shed, keeping the temperature there at 1-5° Reaumur: their food was not in any way altered ; and they continued to be milked. The place selected was shaved immediately before inoculating; and the place selected was the posterior surface of the udder, so that the cow was unable to lick it. Punctures were there made, a little deeper than is usual in vaccinating the human subject, and were covered with a linen cloth soaked in the matter. The matter was taken from small-pox pustules, nacreous, and bead-like, before they had lost their transparency, and containing very clear lymph: that he might proceed with still greater certainty, Dr. Thiele kept the lymph for ten or twelve days between glass plates before using it. On the third day after inoculation, a protuberance was formed under the skin ; on the fifth, a pock like the vaccinal pock was visible, which, between the seventh and ninth, contained a limpid lymph and presented a central depression. Between the ninth and eleventh day, this pock began to desiccate, and to form a crust which, when it fell off, left a small, smooth cicatrix. Dr. Thiele generally obtained one or two pocks from about three or six inoculated punctures. In 1840, Dr. Ritter, of Munich, announced that he also had inoculated cows with small-pox. He stated that during ten years he had experimented on more than fifty cows without the least success, but that at last, having adopted Dr. Thiele's plan, he obtained his results. He produced cow-pox in. the cow, whence he derived matter which gave children a perfectly normal vaccinia. Concurrently with the publication of the result of Dr. Thiele's experi- ments, Dr. Ceely, of Aylesbury, met with similar success. I shall not relate the details of his experiments, which you will find in extenso in Dr. Steinbrenner's remarkable work. Dr. Sunderland, of Barmen, also tried to get cow-pox by inoculating the cow with small-pox, but he proceeded in a different manner from Drs. Thiele and Ritter. Dr. Sunderland, in Hufeland's Journal for 1830, has described the plan which he adopted, which consisted in covering cows with a woollen blanket taken from the bedding of a man who had died in the suppurative stage of a severe case of small-pox. The blanket was imme- diately taken from the dead man's bed, rolled up in a sheet, and carried to a shed where there were young cows: it was carefully fixed successively on the backs of the animals, and allowed to remain on each for twenty-four hours. Not only did each of the cows wear the blanket for twenty-four hours, but it was after that fixed along their manger, so that they could not avoid breathing the miasmata which it exhaled. After some days the cows ceased eating, drank a great deal, and had fever: about the fourth or fifth day, pustules appeared upon the udder and other soft parts. These pustules followed the usual course of cow-pox, and between their fourth and eighth day they yielded lymph which served for vaccination. This marvellous discovery could not fail to command attention : eagerness was shown to repeat Dr. Sunderland's experiments. The results which he announced had been nowhere obtained, neither in Denmark, where, in 1833, the Government requested physicians to investigate the subject, nor at Berlin, Weimar, Dresden, nor Calcutta. In France, the success was no greater. M. Miquel of Amboise made several fruitless attempts to inoculate the cow with a view to produce cow-pox from the virus of small-pox. Our learned brother of Touraine, however, experimented under apparently the most favorable conditions. Those who have visited the banks of the Loire COW-POX. 109 between Blois and Angers must have seen dwellings excavated in the rocky slopes wherein herds of peasants live crowded together, and only separated from their cattle by slight partitions. Well! M. Miquel had occasion to see an epidemic of continent small-pox prevailing amid that population. It being winter, the cows were shut up in their sheds day and night, so that they actually lived among the sick people. Still, under these circum- stances M. Miquel was unable to find small-pox among the cows : he wrapped them up in the blankets of the sick people, but was not able in a single cow to detect the most minute cow-pock. The plan of Dr. Sunderland, then, only yielded satisfactory results when put in force by himself, unless we take into account circumstances mentioned in the narrative of John Webb which I quoted from the London Lancet, and which certainly cor- roborate the experiments of the physician of Barmen. M. Depaul has recently supported the proposition that small-pox and cow-pox are identical, and that cow-pox is human small-pox transmitted to, and modified by the cow, or in other words, that it is nothing more than mitigated small-pox. An epidemic of small-pox would in his opinion be sufficient to explain, on the principle of contagion, the development of that disease in horses, and the inoculation of the cow with horse-pox would in all probability give rise to a modified form of small-pox-that is, to cow- pox. He says : " Cow-pox when transmitted to man will reproduce itself with its characteristics," that is, with its vaccinal characteristics; and finally, that "tag-sore [clavelee] is nothing more than small-pox in the sheep, and is probably the same as small-pox in the horse," whence, he adds, " it follows that the true secret for mitigating small-pox in the human race consists in causing the disease to pass through another species of animal and in then communicating it to man by inoculation."* I have quoted the opinions of my learned colleague in his own words- opinions which he supported by experiments which seemed, for the moment, to prove that his views were right. In point of fact, small-pox can be transmitted by inoculation to oxen and horses: the inoculation originates in them a pustular affection analogous to cow-pox, but only analogous, for the disease imparted to them is really small-pox. This question ought to be considered as definitely settled by the experiments of a commission appointed by the Society of the Medical Sciences at Lyons. As we have here to do with a doctrine in which theory is intimately associated with practice, and regarding which the holding of unsound con- clusions may lead to and, as you shall see, has led to irreparable mischiefs, I ask you to allow me to read to you some of the salient passages of the report made by M. Chauveau in the name of the Lyons Commission. The learned reporter has first shown that small-pox can be perfectly well communicated to the bovine species by inoculation, to which species it stands in the same relation as vaccinia to man; that is to say, that when an ox is inoculated with small-pox it is thereby made proof against cow-pox, just as a vaccinated man is proof against small-pox. But a much more important practical point is, that " small-pox in its passage through the system of a cow is not transformed into vaccinia: it remains small-pox, and returns to the original state of small-pox when reintroduced into the human species." The experiments of the Lyons Commission upon solipeds gave results similar to those obtained from bovine ruminants. There is only a difference in form. Thus in the cow, the eruption of small-pox consists of pimples so minute as to escape notice unless one is on the outlook for them. Cow-pox, on the other hand, engenders an eruption of the vaccinal type with its * Depaul: Bulletin de 1'Academie de Medeeine, 1863-64, t. xxviii. 110 COW-POX. large and very characteristic pocks. In the horse, also, the inoculation of small-pox engenders a papular eruption in which there is neither secretion nor crust; and although this eruption is much more formidable than that produced in the cow, it need never be confounded with horse-pox eruption, so remarkable for the abundance of the secretion and the thickness of the crusts. Hence it follows, that small-pox and cow-pox, or horse-pox, are different diseases, and that when we vaccinate after the method of Thiele and Ceely we in reality inoculate small-pox. This kind of inoculation of small-pox may possibly be free from danger, the disease being-according to hypothesis-modified in its passage through the cow or horse. Some even believe in a mixed virus, to which the epithet vaccino-variolic has been given. Experiment, however, utterly demolishes this theory. Here, again, we are indebted to M. Chauveau for demonstra- tive evidence. The facts are as follows: A girl of two and a half years of age was inoculated with the so-called vaccino-variolic virus-that is to say, with matter taken from pustules in a cow which had been inoculated with small-pox. This child had, on each arm, three magnificent primitive pus- tules, and at a later period, a disseminated eruption of about fifteen pimples. The pustules on the arm furnished virus with which two very healthy children w'ere inoculated. " On the tenth day, both took simulta- neously very severe general small-pox: the eruption was as confluent as it was possible to be, the fever was very intense, and there were convulsions and vomiting. One of these two children died from the severity of the attack." But this is not all: another child was inoculated with the vaccino- variolic virus taken direct from the cow : on the eleventh day, there was a well-marked local eruption, and three days later confluent small-pox, which for several days placed the life of the child in imminent jeopardy. Finally, in this case there was indelible variolic cicatrices. Here, inoculation only disfigured the child : but I have now to mention another case in which it was a homicidal act. The virus was taken from the horse: the inoculated child had an anomalous form of small-pox, from which it died. Influenced by highly commendable prudential motives, M. Chauveau does not give more circumstantial details of this case, but the details which he furnishes are quite sufficient. By the evidence now adduced, I hold that the question is definitively settled. Both in France and foreign countries, however, successful and unsuccessful experiments may be quoted. Bretonneau in his experiments, which he repeated several times, never obtained any result when he operated on heifers, to which he gave the preference from not wishing to dry up the milk of nursing cows. But other experimentalists were more fortunate. Drs. Haussmann of Stuttgard, Numann, Billing, professor of the veterinary school of Stockholm, Magliari of Naples, Heim of Meschede; Drs. Zybel, Nicolai, and Leutin; MM. With, professor at the veterinary school of Copenhagen, Prinz of Dresden, &c.; lastly, Dr. Bousquet, member of the Academy of Medicine, who has paid much attention to the subject of cow- pox,* Dr. Steinbrenner, MM. Boutet, Maunoury of Chartres, have produced true cow-pox by vaccinating cows with the human vaccine lymph with which they were vaccinating infants. When confronted with these contradictory facts, we are obliged to ask : What is the explanation of the successes and failures ? The solution of the problem is not devoid of difficulty. Must we, to explain the diversity of results, invoke assistance from the question of morbid susceptibility- * Bousquet: Nouveau Traite de la Vaccine et des Eruptions Varioleuses. Paris, 1848. COW-POX. 111 opportunite morbide ? Let us take an example. I assume that some par- ticular disease-say influenza-is prevailing. One individual, living in the midst of the epidemic, is seized with influenza under influence of the slightest cause, while another escapes who is living close to the first, and exposed to the same morbific causes, as well as to others more powerful. During the whole of the course of the epidemic, this individual may be exposed with impunity, and then, at some future time, take influenza without any appreciable cause. There are times when an individual is proof against morbific influences, in virtue of I know not what, in virtue of a special condition, of a peculiar state of the organism ; but whenever this special state ceases, the same organism is easily affected by the smallest of the influences which it formerly resisted. Is it to special states of the organism we ought to look for the explanation of the different results which have followed vaccination of the cow ? Or ought we to call in question the virus employed in the experiments ? Shall we say with Steinbrenner, that the total absence of results observed at a certain period after the early days of the Jennerian discovery, in which successful were in excess of unsuccessful cases, depended on the lymph having in its descent become much weakened in power ? The observations of Fiard and those of Boutet and Maunoury seem to give support to that view : the inoculations of cows which they made with matter of old descent never succeeded, but when they used the matter regenerated in their experiments, they obtained a pock from which they were enabled advantageously to vaccinate children. With Steinbrenner we further ask whether vaccinal matter in its first generation in the cow produces more than local results, and whether, after successive generations in animals, it does not gradually acquire the proper- ties of cow-pox such as they were found by Jenner ? Transmission of Cow-pox from Man to Man.- Circumstances favorable to Successful Vaccination.- The lymph ought to be taken between the Fifth and Seventh Days.-Selection of Subjects from whom the lymph ought to be taken.-Health of Persons who are to be Vaccinated.- Transmission of Syphilis in Vaccination.- Vaccinal Eruptions. Whatever explanation, gentlemen, may be given of the facts which I have now laid before you, it is very remarkable that cow-pox when first introduced had a much greater activity than it manifests in the present day. Jenner foresaw this degeneration: he foresaw it, because he suspected that the virus would lose its power in successive transmissions, and also because he reckoned on the shortcomings of vaccinators. The first propo- sition is to a certain extent established by what I have already told you of the enfeebling of cow-pox in the bovine species itself, which took place by transmission from heifer to heifer. What I am about to say of the manner in which vaccination is too often performed will prove the second proposition. Forgetful of the rules laid down by Jenner, vaccina- tors in place of taking lymph before the eighth day, and by preference on the fifth, waited till the eighth day: that was the general practice, but some physicians did not scruple to use lymph taken even as late as the ninth day. Moreover, no attention was paid as to whether the individual to be vaccinated was or was not in a favorable state for the development of cow-pox. This state of fitness, however, is a consideration of the highest importance, and the frequency with which it has been neglected is the reason why we have to deplore many disappointments in the present day. Let us, then, study the conditions necessary for the reproduction of a 112 COW-POX. vaccine lymph, which will retain its anti-variolous power to the greatest possible extent, and be transmissible from age to age. Jenner pointed out these conditions: Dr. Truchetet has restated them in his inaugural thesis, basing his conclusions upon experiments which he made in my clinical wards.*- Some of these conditions pertain to the virus, others to the subject into whose system it is introduced. If the virus has degenerated, it is, as Steinbrenner says, because the lymph employed has been taken indiscrimi- nately from any individual provided the pocks were normal, no inquiry being made as to the beauty of the pock, its progressive development, or its age. Upon reflection, however, it is evident, that, as the laws of biology are equally applicable to the life of animals and plants, physicians ought always to act in this matter upon principles similar to those which influence the selection of seed by agriculturists, who know that by sowing their fields with the finest grain, they will in return reap from them grain of the finest quality. And, without leaving the domain of pathological biology, it is a well-known fact that after a certain period in the development of the pus- tule, the variolous virus is inert. In 1784, Earle, an English physician, communicated his observations on this subject to Jenner, stating that when he had inoculated with matter from too advanced small-pox pustules no effect was produced. The selection of vaccinal lymph is, therefore, a matter of great impor- tance. Its activity is far from being the same at all its ages. Twenty- four or thirty hours after introduction, it is powerless ; in from forty-eight to seventy-two hours, it has begun to develop power; and on the fourth, fifth, and sixth days, it possesses its maximum energy ; on the seventh day, it has decreased in power, and after from the eleventh to the fourteenth, it is absolutely powerless. Jenner, who at first employed lymph taken on the eighth day, then be- lieved that that was the most favorable time, but he afterwards discovered that on and after the fifth day, the pock contained a lymph perfectly inocu- lable and of great energy: he said that this energy diminishes from the time that the inflammatory areola begins to appear : and not only did he abstain from employing lymph taken after the eighth day, when he could do other- wise, but he preferred to obtain it on the fifth. This wTas likewise the opinion of Delaroque, the French translator of the English physician's work ; it is the opinion of a certain number of the most notable practitioners ; it is Dr. Bousquet's opinion ; and it is also mine. These opinions, gentlemen, have been beautifully expressed in verse by one of our most illustrious poets. Casimir Delavigne, in his poem on Vac- cination, says: " Puisez le germe heureux dans sa fraicheur premiere, Quand le soleil cinq fois a fourni sa carrifere." [Draw forth the auspicious germ in its first freshness, when the sun has five times completed his course.] Casimir Delavigne, in the poem from which I quote, gives with singular felicity and elegant precision the symptoms of cowr-pox which he had observed along with Dr. Pariset, Secretary of the Academy of Medicine. If then you wish to have vaccine lymph possessed of all its power, and of the greatest possible amount of efficiency as a protection from small-pox, you must take it at a sufficiently early stage of the pock: you must take it between the fifth and seventh days inclusive. Matter taken at that period * Truchetet: Quelques Recherches sur la Vaccine. [Theses de Paris, 1855.] COW-POX. 113 produces a large pock, which becomes surrounded by a large and more last- ing areola of inflammation : in a word, a cow-pock is obtained more vigorous than if the virus used had been taken at a more advanced stage. During an epidemic of small-pox, if you can procure no better vaccinal matter, you may vaccinate with lymph taken from a forty-eight hours' old pimple: its activity will be less than if taken some days later, but greater than at the eighth day. When eight-day lymph is used, evolution proceeds more slowly, the papule not appearing till the third dav, whereas, when use is made of lymph taken between the fifth and seventh days inclusive, the papule is visible on the second day. In the former case, the areola appears on the seventh or eighth day, and in the latter, on the fifth or sixth. The one begins to dry up on the eleventh or twelfth, and the other on the twelfth or thirteenth. Finally, while the period for maturation is from eight to nine times forty-eight hours for eight-day lymph, it is prolonged to eleven or twelve nycthemera when the lymph used has been taken be- tween the fifth and seventh days. The choice of the subjects from whom the supply of vaccine lymph is derived, and the health of the persons to be vaccinated are also matters of importance; for if the conditions favorable to the perfect development of a germ are inherent in the germ itself, so likewise are they in the soil wherein it germinates and grows. In respect of the selection of persons from whom to take vaccine lymph, it has been shown that they ought to be in good health and of vigorous constitution, as the pock is much better developed in them than in sickly drooping persons. But, gentlemen, there is a point to which I desire to call your special attention to-day ; it is-never to vaccinate with lymph taken, from one under the influence of the syphilitic diathesis. The transmission of the great-pox by vaccination is a fact which now seems to have been demonstrated. Since the beginning of this century, and particularly in later years, cases of this kind have been recorded both in France and in foreign countries; to them I can add one which you have seen in the clinical wards, and which I shall now briefly recall to your recollection. The patient, a young woman of eighteen years of age, came into the Hotel-Dieu for a uterine affection. As we had at the time some cases of small-pox, I recommended that she should have herself vaccinated. The lymph was taken from a child apparently in perfect health, and from the same lymph four infants in the nursery ward were also vaccinated. Cow- pox was regularly developed in the children, and during their residence in hospital nothing anomalous was noticed, but, unfortunately, when they left we lost sight of them. The young woman had false cow-pox: on the day after vaccination the punctures became salient; they were surrounded by an inflamed areola, and accompanied by itching of the skin ; in four or five days no trace of puncture remained. The patient then left us, but it was agreed that she should return once a fortnight to follow out the treat- ment of the uterine affection. On her first return, twenty-three days after vaccination, she drew attention to the punctures on both arms: two of those on the left arm seemed to have taken : I observed that the pustules were ecthyma. At her next visit, a fortnight later, the pustules of ecthyma were observed to have become transformed into scabs of rupia indurated at the base: in the axilla we found some of the lymphatic glands in a state of indolent turgescence; finally, an eruption of roseola clearly showed that the woman was under the influence of syphilitic poisoning, and that the starting-point of the poison was incontestably the vaccination pustules. Gentlemen, you know how many questions have been recently raised in relation to cases of this kind : the subject is one of grave importance, and vol. I.-8 114 COW -POX. its discussion is not yet closed. If some physicians still doubt the possibility of syphilis being communicated in vaccination, the majority are open to the logic of facts, and remain on the alert. But among those who constitute this majority, what diversity of opinion exists? Some hold that syphilis is transmissible and inoculable through the medium of the vaccine virus; others, absolving the vaccine virus from all blame, hold that the syphilitic virus passes with the blood which has accidentally been drawn in taking the lymph from the pock. I shall not stop to discuss the two classes of facts by which these views are respectively supported, as my own experience is insufficient to solve the difficulty. The fact which I wish to impress upon you is this,-that syphilis has in numerous cases been transmitted in vaccination. I cannot better bring my remarks on this subject to a close, than by quoting some of the conclusions in relation to it which have been arrived at by Dr. Viennois, of Lyons.* I agree with Viennois that one ought never to use vaccine lymph taken from a suspected subject, and that in respect of infants one ought not to take it unless the infant has passed four or five months, the age at which hereditary syphilis usually shows itself by visible signs; for infantile syphilis, even before it appears on the exterior parts of the body, is transmissible. But I cannot in any degree adopt the conclusions of this author when he adds: " If special circumstances make it necessary to take vaccination lymph from a syphilitic patient, great care must be observed so as to draw the pure lymph without the slightest admixture of blood or syphilitic humor." I cannot in any circumstances whatever sanction vaccine matter being taken from a syphilitic subject. It is more a matter of hypothesis than of demonstration, that it is only by the blood that syphilis is transmitted in this class of cases. Besides, it is rather difficult to understand how that which is contained in the serum of the blood, that is the syphilitic virus, should not also be contained in the serosity of the vaccinal pock. Finally, it is so difficult to draw off the vaccine lymph free from " the slightest admixture of blood or syphilitic humor," that the recommendation of the required precaution amounts, so far as I am concerned, to a prohibition. My opinion on this point admits of no modification. Abstain always from taking lymph from a syphilitic subject. In the discussion which took place in 1864 and 1865 in the Academy of Medicine, upon the transmission of syphilis in vaccination, MM. Depaul and Bouvier demonstrated the relative frequency of cases of transmission, and showed that vaccination carried out with lymph derived from a syphilitic child may sometimes assume the character of a real social calamity. Thus in 1856, at Lupara in the Neapolitan territory, Dr. Marone vaccinated in the beginning of November fl certain number of children with lymph in tubes which came from Campo-Basso: it was slightly colored with blood, though as clear and transparent as usual. The first child vaccinated with this lymph was Philomene Listori, aged eight months, and from her the others were vaccinated, of whom, besides Philomene Listori, twenty-two, being nearly the entire number vaccinated, took syphilis. These children were born of healthy parents, and all had, from their birth to the date of vaccination, been free from venereal symptoms. In most of them vaccina- tion took effect on the first trial, but in some the operation required to be repeated. The vaccinal pock was followed by characteristic venereal ulcera- tions, accompanied by swelling of the axillary glands. Then, a little sooner * Viennois: Archives Generales de Medecine, Juin, Juillet, et Septembre, Paris, 1860. COW-POX. 115 in some, and a little later in others, but in the majority about the middle of January, 1857, there appeared eruptions of roseola, impetigo, syphilitic papules, and even pemphigus: these eruptions were soon succeeded by mu- cinous scabs on the lips, the interior of the mouth, on the parts around the anus, on the vulva and on the scrotum, with consecutive enlargement of the posterior cervical and inguinal glands; loss of flesh, and a disturbance of the general health, proportionate to the severity of the case. The mothers, most of whom suckled their infants, contracted syphilis from them. A series of venereal symptoms, at first local, and which Dr. Marone has well described, manifested themselves in these unfortunates. Some of them communicated the disease to their husbands. From fathers and mothers it extended to other members of the family, to children under puberty of both sexes, and sometimes to entire families. Almost all the women who became pregnant miscarried, bringing forth syphilitic infants, or dead foetuses, presenting in some cases traces of syphilis. Most of the patients were cured by specific treatment: there was, howTever, a great tendency to relapses; and in some cases two years and a half had elapsed before the disease was eradicated. Some of the infants died, and several of the adults were in jeopardy. Dr. Marone had taken lymph from the first series he vaccinated for the purpose of vaccinating others. Eleven of this second series contracted syphilis like the first, and communicated it to their mothers, who gave it to eleven nurs- lings who had not been vaccinated. Some of the women gave the disease to their husbands, and all the young girls were also affected through their contact with the nurses and children. It appears, therefore, that at Lupara thirty-four children were inoculated with syphilis in being vaccinated ; and that a great number of individuals of different ages were directly or indi- rectly contaminated by these children. At Kivalta there were eighty vic- tims. The details now laid before you are given by M. Bouvier. I have now to add, on the authority of M. Depaul, the history of forty infants con- taminated with syphilis out of forty-six vaccinated in 1821. According to the report of M. Cerioli, there were thus from four original cases 155 chil- dren directly infected with syphilis by vaccination, and there were others secondarily infected through them, bringing up to 300 the total number of syphilitic contaminations. I cannot, therefore, too earnestly recommend you to examine with the greatest possible minuteness the subject froln which you take the lymph for your vaccinations, and to abstain from taking it not only from syphilitic persons, but likewise from all who present the slightest ground for your suspecting that they have venereal contamination. With respect to those whom it is wished to vaccinate, we have to bear in mind age, constitution, certain antecedent diseases, and also the diseases which supervene during the progress of cow-pox. Vaccination succeeds better in childhood than in adult age: it must not, however, be supposed that the younger the infant the greater is the fitness. At the age of some months, vaccination does much better than in the new-born infant. The cow-pock will be much finer in an individual of good health and sound con- stitution that in one who is weak and drooping. In the latter, the vaccinal pimple is softer and less prominent, its areola is smaller, of a dull-red color, and desiccates at an earlier date. M. Truchetet, finding by experi- ment that lymph taken from persons of unsound health became very feeble in its third generation, abandoned the use of it after two transmissions. Acute antecedent diseases have no effect on vaccination, provided the child has recovered its health. Small-pox and cow-pox, however, are exceptions to this law; it may be superfluous to say so, after what I have several times repeated, to the effect that there is an antagonism between 116 COW-POX. the two diseases, and that they reciprocally confer immunity from one another. Nevertheless, cases have been cited, and I have also seen cases, in which vaccination took effect in persons who had had small-pox previ- ously ; but such cases are very rare, and when they are looked into, it is generally found that the cow-pox was of a feeble, spurious kind: regular cow-pox after small-pox is exceedingly uncommon. Examples of antece- dent vaccination not preventing a subsequent vaccination from producing cow-pox have been occasionlly noticed from the date of Jenner's-discovery downwards; indeed two cases of this class are recorded by Jenner himself, in which vaccinated persons went through normal cow-pox a second or even a third time, but at long intervals. Such cases, however, are at least quite as exceptional as the occurrence of cow-pox in persons who have pre- viously had small-pox. Is there anything surprising in these returns of the disease ? Was it not known that small-pox might attack the same person more than once? Why then, may not its congener cow-pox likewise offer sometimes an excep- tion to the general rule ? Such exceptions were, moreover, much more uncommon formerly than now that the vaccine lymph in general use has undoubtedly become degenerated. But before pronouncing any opinion on the number and value of these second attacks, it is important among other things to ascertain whether the persons in whom vaccination has taken effect more than once have ever had previously the legitimate cow7-pock, in what conditicfc. it was developed, in what manner vaccination was per- formed, and what was the date of the first vaccination ; it is particularly important to ascertain positively that the second vaccinal eruption is not that which is called false cow-pox, which may sometimes be mistaken for the true, and to which I shall return, as it is indispensable to be acquainted with the differential diagnosis of the two affections. It has been also asked, gentlemen, w'hether cow-pox, an affection which so radically modifies the economy, and is in the opinion of some observers only a form of small-pox, does not sometimes declare its presence by a general eruption : indeed, there is room for surprise that such is not ordi- narily its mode of manifestation. I have often recalled to your attention a case which I saw in the Necker Hospital, and I am not the only vaccinator who has observed cases of this kind. I vaccinated a strong young child, leaking eight punctures. Eleven days afterwards, to my great astonish- ment, I saw on the face, trunk and limbs twenty-seven pocks having exactly the appearance of cow-pox. I confess that at first I believed in a general eruption, like that which follows variolous inoculation, but on a closer examination I abandoned that idea, or at least I entertained great doubts as to its correctness. Before vaccination, the child had sudamina all over the body. It was summer. He scratched the vaccinal pimples which were excoriated, and thus he carried the virus on his nails to parts denuded of epidermis, and so produced on these parts vaccinal pocks. Inoculation of cow-pox in a recently vaccinated child takes place readily, but the time comes when attempts at this kind of secondary vaccination prove abortive. You have often seen the experiments which I have made in the wards in relation to this point. I vaccinate : in four days I make a new punc- ture with a lancet charged from one of the incipient pustules; I continue to do this daily; and you have seen that up to the ninth and sometimes till the tenth day-but not later than that-there is a cow-pock developed at each new puncture. The secondary pocks, however, do not attain to the size of the primary pock, and it is observed that the secondary pocks earliest in date are the best developed, and that in succession, as the date of the puncture from which they proceed becomes more distant from that COW-POX. 117 of the original vaccination, they lose the normal appearance, those of the ninth and tenth days aborting soon after being slightly inflamed ; whilst after the tenth day, the prick produces no more effect than if the lancet were charged with the pus of an ordinary boil. Our little patient of the Necker Hospital must therefore, have secondarily vaccinated himself, at latest, seven or eight days after the primary vaccination. The general pustular eruption of which I have just spoken, and the occurrence of which is altogether exceptional, must not be confounded with a secondary eruption very common in small-pox, and of which physicians give different explanations. On the seventh, or at latest on the eighth day after vaccination, fever is lighted up, analogous to the fever of maturation in small-pox. It is generally, and I think correctly believed that this fever is symptomatic of the very acute inflammation going on around each pock, and of the swelling of the axillary lymphatic glands. Another interpretation is, that it is simply the general fever of invasion dependent on the disturbance of the system caused by the reception of the vaccine virus, just as the fever of the eighth and ninth day after variolous inocula- tion is nothing more than the invasion-fever of the small-pox then becom- ing developed in the system, and not at all a symptom of the inflammation manifested around the pustule of inoculation. Looking at it from this point of view, we are obliged to hold that the vaccinal fever is not the necessary consequence of the general cutaneous eruption, differing in this respect from the eruptive fever in small-pox and measles. But as the secondary vaccinal eruption occurs very often, and as in summer as many children have it as escape it, the question may be asked, whether the initia- tory vaccinal fever may not, up to a certain point, be analogous to scar- latinous fever, which, as I shall have to tell you on some future occasion, is not always followed by the specific exanthem. Finally, without going in search of explanations more or less hypothetical, we may consider the erup- tion frequently seen about the tenth or eleventh day after vaccination to be nothing more than that exanthem so common in children having sup- puration going on in some part, and at the same time, fever and copious sweating. In point of fact, gentlemen, the secondary vaccinal eruption differs in no respect from that which I have called sudoral eruption, regarding which it is my intention to speak in an early lecture. It is a measly or scarlatiniform exanthem, almost always very transitory, some- times, however, taking the more severe form of acute eczema, or impetigin- ous eczema, and constituting the first link in the very long chain of sup- purations of the skin and mucous membranes which have caused a sort of reprobation of vaccination still existing among prejudiced and ignorant people. Let us now return, gentlemen, to other conditions which modify cow-pox. Chronic diseases, by reducing the vital power of the economy and weak- ening the constitution, necessarily produce a condition unfavorable to the development of cow-pox. Infants with hereditary syphilis readily take the cow-pox, whether the syphilis be still latent, or whether it has showed itself by unmistakable visible signs. Without entering into too much detail, I would, in proof of this assertion, remark that you have often seen in my wards the normal development of cow-pox in infants who at a later period showed symptoms of hereditary syphilis, as well as in other infants who were admitted to be treated for syphilitic psoriasis, rupia, and other vene- real affections. Syphilis, then, does not constitute an obstacle to the development of cow-pox. It is not so with the eruptive fevers. For example, when measles or scarlatina supervene during an attack of syphilis, 118 COW-POX. the progress of the latter is arrested, and is not resumed till the exanthem- atous disease has run its course. As small-pox and cow-pox mutually exclude one another, it seems ra- tional to believe that the two diseases cannot coexist. Again, it has been demonstrated that the incompatability of the two is not declared till the fifth, sixth, or seventh day of normal cow-pox. If the system is under the influence of the variolous poison during a few days immediately succeeding vaccination, the small-pox and the cow-pox both germinate and become simultaneously developed without in any way influencing one another. The experiments of Woodville leave no room for doubting this, and M. Bous- quet states that Professor Leroux has seen a vaccinal pock implanted, as it were, in the centre of a variolous pock. " He separately inoculated the two viruses: vaccination produced cow-pox with all its advantages, and variolation produced small-pox with all its dangers." I have seen the two diseases develop themselves simultaneously. I am well aware, and I ought to tell you, that statements have been published in contradiction to the cases I now refer to as having seen. Thus, a physician of Dunkirk, Dr. Zandyck, concluded from experiments which he made during an epidemic of small-pox, that persons vaccinated during the incubation of small-pox always had modified small-pox with its symptoms and characteristics. Similar results were obtained in experiments made by MM. Rayer, Herard, and Tardieu. The latter has even recorded a case in which he saw success attend vaccination performed at the beginning of a variolous eruption. Although this case is unique, Dr. Zandyck does not the less decidedly give his opinion that vaccination ought to be practiced under these circum- stances, inasmuch as the dangers never originate in the cow-pox, but in the small-pox simple or complicated : most assuredly he is right. Dr. Zandyck is of opinion that the affection-cow-pox or small-pox-which is first in possession, influences, but is not influenced by the other.* I have, however, told you that the experiments of Woodville and Bousquet, as well as my own, demonstrated that cow-pox and small-pox become simultaneously developed, without exerting any influence on one another; and my obser- vations have been confirmed by the paper of M. Marc d'Espine, published in the Archives Generales de Medecine for June and July, 1859. You have recently had under your observation a new proof of the cor- rectness of this opinion. A mother and her infant of two months old simultaneously took small-pox in our wards. The mother, though never vaccinated, had the distinct form of the disease, which ran a course like that of modified small-pox; but the infant had a confluent eruption, and died on the eleventh day. This infant had nevertheless been vaccinated on the second or third day of small-pox incubation: the vaccination ran a perfectly normal course, there being, however, only one pock from six punctures. On the eighth day, a period at which there was no ground for supposing that the child was breeding small-pox, two new punctures were made below the pock, when two other pocks developed themselves in a regular manner. It was not till the third day of the variolous eruption that all the vaccinal pocks appeared modified in their mode of evolution: they were then the seat of hemorrhage which extended to the surrounding cellular tissue, and the subvaccinal ecchymosis became very hard. You have seen that in this case the patient derived no benefit from the cow-pox, which did not prevent death from confluent small-pox. It is but fair, however, to remark that this child was only two months old, and that the * Zandyck: Essai sur 1'Epidemie de Variole et de Varioloide qui a regne a Dunkerke en 1848, et 1849. Paris, 1857. COW-POX. 119 termination of small-pox, as well as of erysipelas, is almost always fatal at that early age. As a set-off to this unfortunate history, I must mention a case which several of you had an opportunity of seeing in 1861, and which tends to support the opinon of MM. Zandyck, Bayer, Herard, and Tardieu. The patient was a male infant of eleven months, whom I had vaccinated during the incubation of small-pox. The progress of the cow-pox was retarded up to the eighth day ; that is to say, the pimples did not show themselves till the fifth day, and the pustular development proceeded exceedingly slowly. On the eighth day, the child was seized with fever, vomiting, and diarrhoea, which continued for two days, and on the following day the variolous erup- tion appeared. It pursued its normal course till the fifth day, when the pustules became dry and crusted. The small-pox had then been modified by the cow-pox, which, on the very day of the appearance of the small-pox eruption, showed itself in beautiful pocks which followed a regular course. To sum up what I have said on this subject: If you wish to propagate efficient cow-pox, you must select your virus under circumstances as favor- able as possible for securing its activity, you must take it from children who are healthy and of sound constitution, you must choose pocks which are large, beautiful, in full bloom [bien fleuries], if I may be allowed the expression, and which are from five to seven days old. However we may explain it, gentlemen, taking into account all the conditions and circumstances to which I have directed your attention, it cannot, in the first place, be denied that it is much more common nowadays than at the commencement of the century, to meet with anomalous cow-pox, which bears the same relation to cow-pox as modified small-pox bears to small-pox: and in the second place, all vacinnators have seen-as I have seen-a very considerable number of persons with cow-pox who had been previously vaccinated. The normality of the first vaccination had been proved by insusceptibility to revaccination lasting for a number of years, by immunity from epidemics of small-pox, and also by the length of time which elapsed before successful revaccination was possible. By vaccinating from arm to arm, there is certainly the least risk of failure; but as we cannot always have recourse to the pock itself, we are frequently compelled to use preserved lymph. I do not propose to enumerate the different plans of preservation which have been devised. You are acquainted with the method of placing the lymph between two perfectly smooth plates of glass of about two or three square centimetres: the dried lymph between the glass plates (which are closely applied the one upon the other), may be kept in this way protected from air and light, provided the plates are, as is usual, enveloped in tin-foil. The method which I prefer consists in shutting up the lymph in capillary tubes-not in vial tubes, which are most objectionable, as it is impossible to fill them with the virus, which consequently is left in contact with air, and so does not keep. The tubes which I recommend are in the strictest sense capillary: as you have often seen them employed, you know that the proceeding is simplicity itself. When you wish to fill them, you open a vaccinal pock J)y making very slight scarifications, in the elevated epidermis; forthwith, an exudation of minute drops of serosity is seen: this lymph is collected by moving over the surface of the pock the extremity of the tube, which ought to be held almost horizontally: the liquid is drawn into the tube by capillary attrac- tion. The proceeding is continued till the tube is nearly full, when it is closed by holding in the flame of a candle, first, the end by which the lymph entered, and then the other. When you wish to use the lymph, you break off both extremities of the tube, place one of them between the lips 120 COW-POX. and blow through the tube, placing the other extremity upon the thumb- nail or the blade of a lancet; a small drop is then deposited. I need not describe the operation of vaccination. You all know how to perform it, and you likewise know the place which ought to be generally selected. There are just two matters of detail to which I wish to refer; the one is the number of punctures which ought to be made, and the other, the circumstances under which it is expedient to select another than the usual place for operating. How many punctures ought to be made? This is not an unimportant question. Although the production of a single pock is generally sufficient to confer immunity from small-pox, the labors of Eichborn have demon- strated that it is not always sufficient. Dr. Marson, an English physician, has lately conclusively confirmed this opinion of the German pathologist. He has shown, from excellently handled statistical data, that of the vac- cinated persons who take small-pox, those have it in the mildest and most modified form who bear more than one vaccinal cicatrix. Here is a summary of Dr. Marson's observations as given by my friend Dr. Lasegue. Of 768 small-pox patients with one cicatrix, 550 had the disease in a mod- ified form, and 3 died, giving a mortality of 3.9 per 1000. Of 608 with two cicatrices, 486 had modified small-pox, and 1 died, giving a mortality of 1.6 per 1000. Of 187 with three cicatrices, 156 had modified small-pox. Finally, of 202 individuals presenting four or more vaccinal cicatrices, 182 had modified small-pox, and none of them died. These figures speak with emphasis, and taken along with others less decisive, though valuable, demonstrate that the number of punctures made in vaccinating is a matter of importance. There is a prejudice against which I wish to put you on your guard, viz., prohibiting the washing or bathing of the infant on the day of vaccination, and for some days afterwards. The uselessness of these precautions was shown by experiments made in 1863 by Dr. Peter, then my chef de clinique, now my colleague in the hospitals, and Professor agrege of the Faculty. Acting on my recommendation, Dr. Peter, after vaccinating a child by means of three punctures on each arm, immediately washed the right arm with a copious splash of water, at the same time rubbing it vigorously. The vaccinal eruption not only appeared on the right arm of all the infants thus treated, but, by a strange chance, the pustules were most numerous and most beautiful on the washed arm. This experiment was repeated on more than sixty infants, and as the results were always similar, it is evident that we ought to give no countenance to the puerile prohibition of ablution for some days after vaccination. Besides, how can one believe in the absorption of the virus being hindered by bathing or washing, when the experiments made in 1862 by Dr. Martin demonstrated that it was not prevented by cauterization. This young physician, who was an interne at Saint Lazarus Hospital when he made the experiments, applied potassa fusa [caustique de Vienne] to the punctures of vaccination some minutes after he made them, and the deep cauterization thus produced did not prevent absorption of the virus, although it prevented vaccinal pocks from appearing: it was found that the subject so treated acquired immunity, and that subsequent attempts to produce cow-pox were ineffectual.* The consideration of the rule to be followed in selecting the punctures, and the modifications which may be required in that rule, lead me to speak of vaccination as a means of curing vascular naevus maternus. This method of treating erectile tumors has been practiced in England by Hodgson, * Peter: Des Maladies Virulentes Comparees, 1863, p. 17. COW -POX. 121 Earle, and Cumming; and is mentioned by numerous French practitioners, some of whom have also employed it, particularly Baudelocque, Layer, Velpeau, Bousquet, Paul Guersant, Pigeaux, Lafargue of St. Emiliou, Cos- tilhes, Laboulbene, Marjolin, Blache, &c. It otters the double advantage of conferring vaccinal immunity, and of getting rid of an affection which, at a later period, by assuming increased development, might become at least a serious infirmity, though not exactly a disease. Legendre has published a note on this eminently practical subject in the Archives Generates de Mede- cine for May, 1856. Our lamented colleague, in publishing a case which had come under his observation, has formulated some practical rules. He says, that before vaccinating an infant, inquiry ought to be made as to whether it has naevus, for it is obvious that if this method of cure is to be employed, it must be had recourse to uninterfered with by antecedent vac- cination. When the existence of an erectile tumor is ascertained, it ought forthwith to be treated by vaccination. This rule extends even to those which are likely to disappear spontaneously, as the proceeding involves no risk, and as it often happens that simple vascular stains on the skin hardly causing the slightest elevation, and resembling flea-bites in appearance, ultimately become bulky tumors. As vaccination cures nsevi by the inflammatory process set up in connec- tion with the development of the pock, it follows, that in proportion to the size of the erectile tumor ought the vaccinal punctures to be more or less numerous. For the same reason it is important that all the pocks should be freely developed, and to secure this the vaccination should be made from arm to arm on the fifth or sixth day of the pock, so that virus employed may be at its maximum of activity. The punctures ought to be so made as only to involve the superficial lymphatic network of the skin, and the lancet must be newly charged for each puncture. To avoid bleeding, of which there is risk when the tumor is very vascular, it may be well to substitute for the lancet a needle, or an exceedingly fine-pointed instrument, such as several practitioners have had made for this particular operation. Some have recommended that the vaccinal punctures be made around, and not in the erectile tumor. By adopting that plan there is obtained a series of pocks which, being partly on the sound skin and partly on the naevus, circumscribe and invade the latter, determining an inflammation which accomplishes a complete cure. When the vaccinal crusts fall off, the place of the tumor is found to be occupied by a smooth cicatrix, which is either perfectly white or still dotted with a few red points: these red points are isolated, not elevated, in size not larger than a small pin's point, and their increase in volume is rendered impossible by their being situated on cicatrix- tissue. This method of treatment is applicable when the naevi are situated on the trunk and limbs, but not when they are on the face, as in the latter situation the cicatrix will be very extensive, and may even be larger than the naevus. Modified Cow-pox.-Regeneration of Lymph.-Revaccination.- Vaccination at the Bar of Public Opinion. I said that I should return to the subject of false cow-pox, an affection which it is necessary to be able to recognize, so that it may not be mistaken for true cow-pox. It has been thus described by M. Bousquet: "True cow-pox hardly begins to show itself at the end of the third day, but the false is much earlier, and may be seen from the first to the second day after introduction of the virus, a circumstance which from the first 122 COW -POX. constitutes a distinction between the two affections. But this precocity is not by itself sufficient to establish a differential diagnosis. False cow-pox is sometimes so rapid in its course as only to appear that it may disappear: at other times it shows itself in the form of a small pimple, more appreciable by the eye than by the sense of touch. This pimple goes on increasing in size till the fourth or fifth day, leaving the physician uncertain as to its future progress; but on the sixth or seventh day, in place of becoming developed, its progress is arrested, it grows pale, and dries up: at other times it advances farther, always preserving in its rapid development a conical and globular shape, which I look upon as an unerring a sign of false cow-pox as the flattening and central depression of the pock are signs specifically characteristic of the true." " The false pock is sometimes red and sometimes yellowish. It never assumes the brilliant silvery lustre which distinguishes the prophylactic cow-pock. Though not exactly irregular in shape, it has an ill-defined margin. Some time between the fourth and seventh day-for the false cow-pock has nothing fixed or normal in its course-it becomes yellow, suppurates, and dries up." To this description it may be added, that false cow-pox is often accom- panied, as local symptoms, by inflammatory induration of the subjacent cellular tissue, disagreeable itching in the affected parts, swelling and pain in the axillary glands; and, as general symptoms, by restlessness, headache, and sometimes by fever. There is another kind of false, or, to speak more correctly, of aborted, cow-pox. It is met with when the pustules of true cow-pox have their development arrested or impeded by excoriations caused by the scratching of the infant, by the pressure of too tight clothes, or by the irritation of unnecessary handling. Under such circumstances the suppuration begins at once: the pustule becomes yellow, swells, and its virulent lymph disap- pears. The term false cow-pox which I have employed is not quite a correct term. Gentlemen, neither false cow-pox nor false small-pox has any exist- ence. When the economy is in no state of aptitude for receiving or devel- oping the virus of small-pox or cow-pox, the puncture made in vaccinating produces no more effect than if the lancet had been charged with pus from a common boil; when there is some partial aptitude, the result is abortive cow-pox at the end of some days ; when there is a state of still greater apti- tude, the pock, quicker in its evolution than in the normal order of events, closely resembles that of regular cow-pox ; but it passes away more rapidly. In a word, we have modified cow-pox, just as we have modified small-pox. I have described the manner of propagating that legitimate cow-pox, which will confer immunity from small-pox, and have pointed out the man- ner of preventing degeneration of the virus. But is it possible to regenerate virus which has lost its original energy? It certainly would not be difficult to do so if one could always go back to the original source-provided we could always obtain cow-pox from the cow. Unfortunately, that is impos- sible. The question then is, Can we, in the circumstances in which we are placed, by any means accomplish that object so much to be desired, the regeneration of vaccine lymph ? Cannot we, by taking lymph of the best quality and propagating it through a succession of the most favorable sub- jects, do the same for it which horticulturists do for plants, when, from seeds of the most commonplace kinds, they obtain, after a succession of genera- tions, the most beautiful varieties, by always sowing chosen seed in chosen soil ? The observations which I made, along with M. Delpech, on the inocula- COW-POX. 123 tion of small-pox, give credibility to this supposition. A girl of 17, whom I had vaccinated in her infancy, was admitted into my wards at the Necker Hospital, with mild modified small-pox. With variolous matter taken from this young girl I inoculated a child, making only one puncture: the pustule of inoculation became developed, without any other eruption being produced. A second child was inoculated with matter from the first: in this case, the development of the inoculation-pustule, there was a secondary variolous eruption in the distinct form. A third child was inoculated with matter from the second : in this case the eruption was more abundant. Last of all, in the fifth generation, the variolous eruption was confluent : the small-pox had become regenerated. Why has not a similar plan been pursued with vaccine lymph ? Experi- ments were instituted under my observation by M. Truchetet in the wards now under my charge. We employed lymph taken on the sixth day, that is to say weak lymph which did not become papular till the third or fourth day, nor pustular till the sixth, nor surrounded by an areola till the seventh, nor desiccated till the tenth ; nor did the crusts fall till about the fifteenth day. We inoculated a healthy child : we took matter on the fourth or fifth day from this child, and successively transmitted it to other children in the best possible state of health. After a certain number of genera- tions, the lymph appeared to us to have become more energetic, to mani- fest its effects more quickly, and to take a longer time to complete its evo- lution, than the lymph with which we commenced the series of inoculations. Not wishing to put too much reliance in our own impressions, a child was sent to the mairie of the eleventh arondissement to be vaccinated. On the eighth day, lymph was taken from this child, and with it the left arm of a healthy child was vaccinated, while, at the same time, the right arm was vaccinated with lymph taken from a subject in our wards. Several other children wrere vaccinated in the same manner, and our impression was that our " regenerated" lymph was more energetic than the lymph used in the town. As the results of these experiments challenge a positive admission of the doctrine that vaccine lymph can be regenerated, they ought to be repeated and generalized. Unfortunately, it cannot be denied, that the lymph in common use has become degenerated ; and this, as I have pointed out, is perhaps exclusively due to the unfavorable circumstances under which the practice of vaccination is carried out. As in the present day, vaccination gives in many cases oidy temporary immunity in place of the absolute immunity which it seems to have imparted at the beginning of the century, it is incumbent on us to revert to revaccination, a practice which has been long ago lauded. Immediately after the promulgation of Jenner's discovery, as I have already had occasion to remark, doubts arose in England regarding the value of vaccination : even then, many physicians had proclaimed the necessity of revaccination after the lapse of a certain time. In France, at a later period, Drs. Berland, Boulu, Caillot, and Genouil stated their belief that the prophylactic power of vaccination was limited to ten, twelve, fourteen, fifteen, seventeen, eighteen, twenty, and twenty-five years. In 1825, M. Paul Dubois undertook the refutation of these statements, and rejected revaccination as a useless practice, although he admitted the apparently conclusive character of the facts on which it rested. In 1838, this important question was submitted to formal discussion in the Academy of Medicine, where revaccination encountered numerous adversaries, but where it also had most eminent defenders, such as Chomel and Bouillaud. The Academy adopted the conclusions of the commission appointed to 124 COW-POX. report on the subject, which conclusions were adverse to the practice of revaccination. This decision, supposed to have been a definitive settle- ment of the question, was warmly defended by M. Dezeimeris, in his jour- nal, the Experience. He based his arguments upon numerous facts observed in France, and on rigorous statistics collected in Northern Germany. On the other side, Drs. Fiard and Hardy protested against the decision of the Academy-Dr. Fiard in a letter addressed to that scientific body, and Dr. Hardy in a paper published in the Experience, in which he showed the agreement of the documentary evidence from England with that supplied by Denmark, Sweden, and Germany, and adduced by Dezeimeris. Notwithstanding the diversity of opinion now noticed, revaccinations on a great scale were performed in the northern countries of Europe, particu- larly in Germany. Since 1823, every soldier, on admission into the Prus- sian army, has been immediately revaccinated. The practice, thus adopted in foreign countries, was in the first instance condemned in France, not- withstanding the vigorous manner in which some defended it, and although followed by numerous physicians of the highest repute, including Favart, Rayer, Robert, and many others: it was afterwards mildly recommended, and has at last been accepted as a proper proceeding. Revaccination is now' the rule in public practice, and it has been made obligatory in the French army. Epidemics of small-pox have only made it too clear, that when small-pox prevailed in a population, persons who had been long previously vaccinated were struck, and that the disease was most severe in those in whom the date of vaccination was most remote. The history of epidemics ought to tell us what is the influence of revac- cination upon the progress of small-pox, and I cannot give you a better example of the information which they afford than by laying before you the abstract of the excellent wTork on this subject by Dr. Gintrac, pub- lished in the Gazette des Hdpitaux of 11th July, 1857 : " In a parish containing a population of about 2600 souls, a young woman who had been vaccinated was attacked, towards the end of Oc- tober, 1853, with small-pox contracted during a long residence with a relation suffering from that disease. During the w'hole of her illness this young woman was attended by her mother, who also took the disease, although she was fifty-seven years of age, and had been vaccinated. Both recovered: but, early in January, at the beginning of the mother's con- valescence, the disease wTas becoming epidemic. It invaded families, attacking each member in succession or simultaneously. In January, the number of persons seized exceeded 180, and by the 10th of February it had reached nearly 260. From day to day, the number rapidly increased. Men and women, vaccinated and unvaccinated persons, those who had had and those who had not had small-pox, yielded in almost equal proportions to the epidemic influence." No opportunity could have been more favorable for studying the influ- ence of vaccination upon the course and severity of small-pox. Dr. Gin- trac, recapitulating the facts which he saw, has drawn the following con- clusions : " There were no cases of small-pox in vaccinated subjects under twelve years of age. The greater the age of those attacked, or in other words, the longer the interval since vaccination, the greater was the severity of the disease. Some families strikingly exemplified the remarkable relation which existed between the more or less advanced age of the patient, and the greater or less severity of the attack. In a family of eight, father, mother and six children, the parents had confluent small-pox; three sons, aged twenty-six, twenty-three, and twenty-two respectively, had the disease COW-POX. 125 less severely; two sons, aged eighteen and fifteen, had modified small-pox ; and the other son, aged twelve, though constantly exposed to the contagion in the same room with the others, had no eruption at all. In another family consisting of seven persons occupying the same lodging, five were struck down by the epidemic, of whom three had been vaccinated between twenty and thirty-five years, and two from fourteen to fifteen years pre- viously. In all of them, there was a great similarity in the prodromic symptoms and eruption, but when the disease attained the suppurative stage, those who had been most recently vaccinated recovered in a few days, and the others suffered severely and had prolonged suppuration." "It was ascertained that in general, the disease was decidedly modified, and essentially milder, in those who had been vaccinated : in them the duration of the attack was less than half of the usual duration. There were only prodromic and initiatory symptoms ; when the period of suppura- tion was desiccation took place, and the disease seemed from loss of power to be unable to proceed any farther. There were no fatal cases among the patients who had been vaccinated. Ten deaths occurred among the unvaccinated. The ages of those who died were one, two, twenty-one, twenty-three, twenty-seven, twenty-nine, thirty-one, fifty-two, fifty-five, and fifty-seven. In all of these cases, death took place during the suppurative period." " In February, 1854, when the epidemic was daily striking down many individuals, the question of vaccination and revaccination was keenly dis- cussed. It having been at last decided that both should be practiced, they were immediately resorted to. In less than ten days, 180 vaccinations and 712 revaccinations were performed. The result surpassed the most sanguine hopes." "In 180 persons vaccinated for the first time, 171 had true prophy- lactic pocks, which furnished lymph for vaccination; and in the nine remaining persons, there was no result." " The possibility of vaccination taking effect twice in the same person is no longer doubted: it is nevertheless necessary to inquire what modifica- tion the vaccinal'fermentation undergoes in persons previously vaccinated, and what is the course of the pocks in a second vaccination. Here are the results of 712 revaccinations. In 302 individuals, the success was com- plete ; the pocks were developed about the fourth day and w'ere full on the seventh : on the eighth day, they in due course became surrounded by an erysipelatous areola, then desiccated, and formed crusts which fell off on the twentieth day. The pocks were umbilicated, and presented indisputa- bly all the characters of the legitimate vaccinal eruption. In eighty-five of the revaccinated, the pocks were modified: they appeared on the third day after the punctures, became filled between the fifth and seventh days with a plastic lymph, became surrounded by a reddish areola, and some- times even caused enlargement of the axillary glands. The non-umbili- cated pocks presented neither the swelling nor hardness w'hich belong to cow-pox, and when the crusts fell no perceptible cicatrix was left. In 119 cases, the introduction of the vaccine virus produced, within twenty-four hours, an acuminated pimple which rapidly disappeared. In 206 cases, no visible effect was produced on the skin. The persons who had been vaccinated and revaccinated, successfully or unsuccessfully, almost all escaped small-pox. There were five exceptions, but in these cases, vaccina- tion only preceded the eruption of small-pox by a few days." " The following are some of the conclusions drawn from the observations made during the epidemic." " Small-pox did not attack indiscriminately and by chance; it generally 126 COW-POX. seized the old and respected the young. If this epidemic has shown that cow-pox is not absolutely preservative, a fact established by the daily occur- rence of sporadic cases, it has at least established that cow-pox exerts a salutary influence upon the issue of an attack of small-pox by shortening its duration and lessening its danger." " Revaccination applied generally to a population during the full tide of an epidehiic, has at once arrested its ravages and destroyed its power of development: it has proved itself to be undeniably prophylactic, and it even seems to have imparted a certain degree of immunity to persons in whom the disease was already incubating. Finally, revaccinations per- formed in the midst of an epidemic have been found to be free from all bad consequences, notwithstanding the fears of evil which were entertained by some physicians." The results of Dr. Gintrac's experiments agree in a remarkable manner with those obtained on a large scale in Germany, Denmark, and Sweden, of which you will find an account in the essay of Dezeimeris, in volume second for 1838, of the Experience. The statistical summaries of the German authors, applicable to the four years, from 1834 to 1837 inclusive, prove that the occurrence of cases of small-pox became more and more unusual, just in proportion as re-revac- cination became more and more practiced. I cannot place before you all the tables which have been drawn up in illustration of this subject, and must confine myself to the following brief abstract, which will give you a fair idea of the facts. In 1834 there were 619 cases of small-pox; in 1835, there were 259 cases; in 1836, there were only 30; and although in 1837 the number was 94, that was very much under 619. Other statistical summaries also corroborate that which was demonstrated by Dr. Gintrac's observations, to the effect, that the immunity derived from vaccination had become weak and temporary, and also that more than twenty-five years ago, the utility of re-revaccination was great. From the summaries referred to, it appears that of 44,000 persons who were revac- cinated, 20,000 had the legitimate cow-pock, a result which superabundantly showed that nearly half of those operated on had lost their vaccinal im- munity. Nine thousand had had abortive cow-pox. It was only in fifteen thousand that vaccination produced no other effect than a slight redness, lasting from twenty-four to thirty-six hours, round the place where the punc- tures had been made. Similar conclusions were arrived at by Dr. Marc d'Espine, of Geneva. You will find his papers in the Archives Generales de Medecine for June and July, 1859. Another question has now to be solved : What is the duration of vaccinal immunity? Or otherwise expressed: At what age, and how often, ought individuals to be revaccinated ? So long ago as 1804, Dr. Godson raised doubts as to the preservative power of vaccination, and alleged that it did not confer immunity for more than three years ; but on the other side of the question, Jenner then showed that the duration of the preservative power was much longer, by adducing cases in which he had ineffectually attempted to inoculate with small-pox persons who had had cow-pox, in one case, twenty-three, in another twenty- seven, and in a third fifty years previously. However, in the early days of vaccination, the immunity which it gave seemed so protracted as to lead to the belief that it might continue during the whole of life, but afterwards, when it became admitted that the immunity was not perpetual, endeavors were made to ascertain its limits. I have already said that, in France, Drs. Caillot, Boulu, Berland, and Genouil had each fixed these limits, the COW-POX. 127 first at ten or twelve years, the second at fourteen or fifteen, the third at seventeen or eighteen, and the last-mentioned physician at from twenty to twenty-five years. But it is impossible to name any absolutely precise period. For example, I revaccinated three of my daughter's children: in the eldest, aged seven years, and in the second, aged five and a half, I saw normal cow-pox reproduced three years after their first vaccination, while in the third, who was under four years, there was no result when I vaccin- ated her the second time. Dr. Marc d'Espine, holding very much the same opinion as Dr. Caillot, says that the first revaccination ought to be performed between the ages of ten and fifteen. He says, that inasmuch as the generalization of vaccina- tion has advanced the age of the maximum frequency of small-pox from infancy to adolescence and maturity, so will the generalization of revac- cination carry it on twelve or fifteen years farther, bringing the maximum to a period of life beyond the age of thirty. Arguing in this way, he suggests the necessity of a second revaccination at thirty, and even a third revaccination about the age of forty. Resting my convictions upon the facts which I have now cited, I gen- erally recommend vaccination to be repeated as nearly as possible once every five years. If this practice is unnecessary, it is at all events free from objection. We ought certainly to endeavor to multiply the chances of im- munity from small-pox-and even from modified small-pox, which, though generally a mild disease, is in exceptional cases attended with danger, a fact I was careful to point out when giving you its history. The principles which apply to the revaccination of persons under thirty- five, are equally applicable to those who have passed that age. Dr. Vleminckx, who recommended revaccination after thirty-five, was met with the objection, that when that period of life was attained the aptitude to contract small-pox had become less, it being alleged that the successful revaccination of persons of fifty and sixty did not in the least degree tend to show the existence of such an aptitude. Maintaining the great principle hitherto generally admitted, that suc- cessful revaccination is proof of the return of aptitude to take small-pox, Dr. Vleminckx threw out the idea, that if the individuals referred to have either become insusceptible or less susceptible to variolous contagion in the ordinary way, they might perhaps contract the disease, if inoculated with the matter of small-pox: he then, defending his practice of revaccination, replied to objectors by reminding them that cases of small-pox were still too common in this very class of persons. The practical conclusion to be drawn from all the facts is, that we ought to prescribe revaccination and a repetition of revaccination according to circumstances, but particularly if an epidemic of small-pox is prevailing; and that we ought to promote the general adoption of revaccination with as much zeal as we bestow on propagating the practice of vaccination, because revaccination undoubtedly augments the chance of resisting vari- olous contagion, and renders the disease milder in those who are not proof against it. Gentlemen, the opposition, the unjust and vehement attacks which the immortal discovery of Jenner encountered when first announced to the world, have been renewed in our day. Within the last few years, some physicians, a very small number it is true, following the path opened up to them by a mathematician, a stranger to our art, have desired to put vac- cination once more on its trial. These vaccinophohists-for that is the absurd name which they have taken-returning to the ideas of Rhazes, who regarded small-pox as a natural and useful depuration of the blood, 128 COW-POX. exhuming the theories and ideas of the celebrated Hoffmann, of Willis, of Violante, and of Hahn (which perhaps, nevertheless, they did not under- stand), have asserted that small-pox was a necessary disease. They say that it is as old as the human race; that it exists as a germ in the economy; that every one has within his body a special proclivity, in virtue of which he must sooner or later be affected ; and, finally, that the prevention of the manifestation of the variolous germ is a proceeding similar to the practice of those who would wish to prevent the manifestation of the herpetic or gouty principle. They go much farther, for they add that cow-pox, by setting itself up in opposition to the external manifestations of small-pox, has originated new diseases more terrible than that which it was wished to destroy, and that in point of fact vaccination has raised the death-rate in Europe. Such, gentlemen, are the conclusions at which statisticians have arrived after long and toilsome exertions! But are they unaware that the statistical weapon has two edges ? Do they not know that from the same elements, from the same facts, one may lead, or be led, to opposite conclusions? Do they not know that a statistician can make statistics say whatever he wishes them to say ? If asked to prove this statement, I shall bring forward as a case in point this very attempt to make out a charge against vaccination. On the one side, the vaccinophobists have used statistics to maintain their accusation, and the defence has equally derived its arguments from the same source. This is explained by the former having been dominated by a deplorable preconceived idea, and by the others having examined the figures in a spirit of enlightened and judicious criticism. If it be a fact that there has been an increase in the rate of mortality in Europe, it would certainly be interesting to study the causes of the increase, but such inquiries would here be out of place, for, as I hope to prove, vac- cination is in any case blameless. Be the conjecture true or false, it belongs to that vast question, the displacement of mortality, which involves as an accredited hypothesis the general principle which leads to the conclusion, that humanity pays the debt of death in accordance with an inevitable and inexorable law. If small-pox played the essential part which some wish to assign to it, if it were a natural depuration of the blood, if it were almost an indispen- sable condition in the economy of the human body, it must have existed from all time. Although Hahn has laboriously disinterred notices of this disease from among the historical remains of Grecian Medicine, one must hold by the opinion held by Werlhof, and reproduced by Van Bwieten. Small-pox was unknown in the times of Hippocrates, Galen, and JEtius: these illustrious observers make no mention of it. If it existed in their times they must have described it, for they could not have disregarded a disease presenting such precise characters. If we admit that small-pox is as old as the world, we must also admit that the germ remained quiescent for many centuries, till an opportunity occurred for manifesting itself. It would be necessary to assume, in respect of the whole human race from the creation, that which Rhazes and the par- tisans of his theory assume regarding each individual, viz., that the morbific germ of small-pox remains concealed in the body, for a longer or shorter period, in a home of its own, which Hoffmann localized in certain parts of the spinal marrow, which Willis, and after him Violante, placed in the suprarenal capsules-capsulis atrabilariis, sive renihus succenturiatis dictis- whence sooner or later, he said, it made its irruption. Need I say that this doctrine is neither in accord with fact nor reason ? Small-pox, then, inasmuch as it has always existed, is not a necessary COW-POX. 129 malady. Nor is it a constitutional malady, for in constitutional diseases there must be a diathesis. Now,what do we mean by diathesis? Diathesis is a special state, a particular proclivity in the economy which is either hereditary or acquired, but which is essentially and invariably chronic: it is transmittible from father to son, and, in virtue of this hereditary power, is reproduced with identically the same fundamental character: in form it is liable to modifications and varieties, but its morbid manifestations are in general strongly marked with a good deal of distinctiveness. Gout and rheumatism, for example, are diathetic maladies. When gout is quiescent during the interval between its attacks, the individual seems to enjoy perfect health ; but when an attack comes on the diathesis manifests itself, sometimes by inflammation of joints, by peculiar secretions in par- ticular parts, such as the joints, the skin (especially that of the hands), the soles of the feet-at other times by neuralgic affections, asthma, gravel, or dyspeptic symptoms. In whatever way these manifestations appear we can generally recognize in them an expression of the gouty diathesis. It is the same with rheumatism : the diathesis which constitutes that disease will make itself known in a great variety of forms, and by very different special lesions of the heart, fibrous tissues, nervous system, &c. These numerous forms of disease are all parts of one disease, which, by attention, we can diagnose. The same may also be said of scrofula. But the essential parts of these diatheses are on the one hand chronicity, and on the other a ten- dency to returns and repetitions, not only in the same individual, but also in his direct and collateral descendants. Thus, a manifestation of the stru- mous or tubercular diathesis in any one organ leads us to fear strumous manifestations in other organs. An attack of gout or rheumatism in an individual makes us expect a succeeding attack; and a succession of such attacks leads us to apprehend that the disease will reappear in his children, for experience has taught us that gout, rheumatism, tubercle, and scrofula, descend from generation to generation. Is it so with small-pox ? Is it so with other contagious diseases ? Small- pox is an essentially acute disease, which runs its course in a determinate space of time, leaving no trace of its passage except cicatrices on the skin. Will any one venture to say that it is hereditary? The cases of intra-uterine small-pox which occur are accounted for by contagion. But are the children of parents who have had small-pox at some former period necessarily vario- lous, as children of tuberculous and gouty parents are born predisposed to tubercle and gout ? There are, however, some points of resemblance between contagious and diathetic diseases, and indeed some have called the former the acute dia- theses. Like diathetic diseases they involve a special disposition of the economy, but they differ from them essentially in being acute, and in not being transmittible by descent: they are caused only by the operation of a special morbific principle ; and thus in a certain way they are transmittible from a sick person to another individual: but they differ from diathetic diseases in being propagated by the transmission of a contagium. From the very fact that small-pox has not always existed, it is evident that it must have become spontaneously developed in its first subject: it has originated, therefore, under the influence of causes which have escaped observation. If, moreover, it should one day disappear from pathology, as has disappeared leprosy, a disease so common in former times, or if it should cease to present the characters by which it is now recognized, it is reasonable to suppose that it can again originate without contagion, under the influence of causes similar to those whence it first sprung. This mode of development VOL. I.-9 130 COW-POX. has hitherto, however, eluded observation, and no one can adduce a single well-established case of spontaneous small-pox. It was originally brought into Europe by contagion, and to this day is propagated by contagion. It is difficult to demonstrate the influence of contagion in great centres of population, where people are so commingled and so confusedly brought into contact with each other, but in small places it is more appreciable. If an epidemic of small-pox break out in a village where no case of the disease has been seen for twenty, twenty-five, or thirty years, it can generally be ascertained that it has been imported by some one who has come from a place where it was prevailing. Among other examples of this, read the cases published by Dr. Gintrac, whom I mentioned in connection with the subject of revaccination : read also the work of Dr. Marc d'Espine, wherein you will see how some epidemics can be followed up to their source. It is not necessary that the person who conveys the contagion should have had the disease. All writers on the subject testify that the variolous con- tagium possesses an inconceivable power of reproduction. The minutest drop of variolous matter, or the effluvia from a living or dead patient, are sufficient to transmit the disease. Moreover, the morbific germ, like certain volatile substances which, for a longer or shorter period, cling to the vases in which they have been shut up, or to the rooms in which they have been placed, has an action vast beyond all appreciable limitation, a divisibility which is infinite: the most imperceptible atom is sometimes sufficient to engender the disease, just as the minutest spark of fire suffices to kindle a conflagration when it falls amid combustible materials. Small-pox is propa- gated by contagion, whether the contagium be communicated by inoculation or by absorption from air carrying variolous effluvia. It is then neither a diathetic, nor an essentially constitutional disease, and still less is it a dis- ease necessary to the human economy, inasmuch as it has not always existed. And, gentlemen, it is not the only new disease. Was not Asiatic cholera a new disease in France when it broke out among us in 1832? I admit that it had been known in India long before that, but even in India where it seems to have had its origin, the date of its appearance is not very remote, as the first well-authenticated epidemic observed occurred in that country about the middle of last century. It is hardly eight years ago since yellow fever was unknown to more than four-fifths of the globe, and to two-thirds of the transatlantic hemisphere. Till then, it had so completely spared South America, notwithstanding the numerous lines of communication estab- lished between north and south, that no case had been seen in the Brazils, Bahia, Fernambouc, Buenos Ayres, and Monte Video. But after that time, having passed the line, it cruelly ravaged these countries, and began to reach the shores of the Pacific Ocean : it is only two years since it appeared at Lima, where it has been neither very fatal nor very severe; and till now it has not been seen in California. Unfortunately, there is every reason to believe that it will continue its progress, and that, proceeding beyond its present limits, it will invade countries hitherto preserved from its ravages. Besides the new diseases-small-pox, cholera, and yellow fever-there are others which have been erroneously supposed to be new, some from the former means of diagnosis having been defective, and qthers from neglect of the histories left by our predecessors. The detractors of vaccination point to these diseases, miscalled new, when they argue that vaccination, by pre- venting the external manifestations of small-pox, has caused the develop- ment of diseases more terrible than small-pox itself. It has been said and written, that through the absence of small-pox, the blood is no longer depu- rated, and the economy no longer put into a condition to resist morbid actions; hence, it has been said, proceed the uterine affections, the diphtheria, COW-POX. 131 and particularly the typhoid fever so common in our day, and by the two latter of which communities are decimated. But there were good reasons for uterine affections having been imper- fectly known. The speculum, which has rendered so great services to uterine diagnosis, was not in common use till Recamier generalized its employment in the beginning of the present century, though it had been invented in the days of Paulus yEgineta, and Rhazes, and modified subse- quently by Ambrose Pare, Scultet, and Garengeot. Fifty years ago, the vaginal examination of the uterus by the finger was unheard of, except in cases of pregnancy : up to that time woman would have revolted at the very idea of such examinations, and no physician would have dared to propose them. Now, it is no longer so, and even our English neighbors have freely accepted the speculum and the toucher. Nowadays, we are likewise better acquainted than formerly with uterine pathology. Neverthe- less, though then but imperfectly understood, uterine diseases existed in the days of our predecessors, as their writings testify. The pathological anat- omy of these affections had engaged the attention of physicians, as you can see by reading the cases recorded by Morgagni, who quotes a certain num- ber from the works of preceding authors.* Although the acquaintance with uterine affections was imperfect in early times, it was considerably diffused even among the general public, as is evident from the very signifi- cant manner in which they are alluded to in the epigrams of the ancient poets. Diphtheria has also been proclaimed as a new conquest of human infirm- ity. In verity, a doleful conquest! It has been said that this terrible disease was unknown in former ages, and did not begin to show itself till after the practice of vaccination had become common. Need I discuss such a proposition as this? Any one possessed of even a very slight acquaintance with the history of medicine is aware that sore throat with plastic exudation [angine couenneuse],t\\Q most common form of diphtheria, was long ago observed and described, and that authors of the most remote antiquity mention it. Iretaeus called it the Syrian and the Egyptian dis- ease, which shows that when he wrote, it was common in Syria and Egypt. Without going so far back into antiquity, but at the same time going back to the sixteenth century, an epoch remote from our own, it may be stated that Spanish physicians of that period described frightful epidemics of angina and croup which ravaged the Iberian peninsula and Italy. The name which they gave to this affection of the trachea was morbus strangu- latorius, and they have also preserved the names by which it is commonly known-garotillo and male in canna. Finally, to come nearer our own times, was not gangrenous sore throat described a hundred years ago, in France, Sweden, Germany, and America, under the names of diphtheritic angina and croup ? Vaccination, therefore, cannot have the discredit of originating a disease which had an existence prior to vaccination. Indeed, if we were to reason after the manner of the vaccinophobists we might rather say that vaccination arrested the development of diphtheria, because by a singular chance never were diphtheritic angina and croup less prevalent than at the beginning of the present century, the very time at which cow- pox began to be propagated by vaccination. The argument upon which the depreciators of vaccination chiefly rest is drawn from their allegation that typhoid fever is a more common disease now than prior to the Jenuerian discovery. In reply, it is only necessary to refer to some pages of the aphorisms of Stoll; for in the short chapter * Morgagni : De Sedibus et Causia Morborum : 45, 46 et 47. 132 COW-POX. which he devotes to putrid fever \Jebris putrida], it is impossible not to recognize our own typhoid fever, portrayed in its most striking characters and with all its symptoms. Is there any difference between it and the ataxo-adynamic fever of Pinel ? Do not the words of Prost, published in 1802, show us this fever, attacking subjects of twenty and thirty years of age, who, be it remembered, had never been vaccinated, and in whose bodies were found on examination after death the very intestinal lesions now regarded as essentially characteristic of dothienteritis ? Similar ana- tomical proofs are also supplied by the treatise of Petit and Serres. These physicians observed the affection, which they described in 1814, in indi- viduals above fifteen years of age, and who consequently could not have been vaccinated. Typhoid fever, then, so inappropriately appealed to, has no connection whatever with cow-pox : it existed long before Jenner, though under different names, such for example, as synochus putris, febris putrida, lafievre adynamique, la fievre nerveuse, lafievre maligne, &c. The physicians whose opinions I am now calling in question-because they have made some noise lately-see in typhoid fever a repressed small- pox, the eruption being, as they say, on the mucous surface of the intestine, in place of on the skin : they repeat the statement of Lecat, comprised in the name of gangrenous mesenteric small-pox, which he gave to an epidemic disease prevalent at Rouen in 1763. I am quite willing to admit that typhoid fever bears a resemblance to small-pox, to this extent, that its symptoms are those of an eruptive fever, and that it has a pimply eruption for its specific anatomical characteristic: but that is not the sense in which I understand that the attempt is made to establish the relationship of typhoid fever and small-pox. The physicians who call typhoid fever a kind of small-pox do not say that typhoid fever and small-pox are analo- gous, but they are identical. They lose sight of the fact that the intestinal lesions of typhoid fever bear no resemblance to the pustules of small-pox. If it be said that the dissimilarity of the lesions is explained by the differ- ence of their seats, I reply, that upon comparing in the most unprejudiced manner possible dothienteritic eruption with variolous eruption on the mucous membrane of the mouth and pharynx, I could not discover any similarity between them. Finally, if typhoid fever and small-pox are the same disease, persons who have had one could not take the other: and this is a point in respect of which facts utterly contradict the theory of the vaccinophobists. You have very recently seen in our wards convalescent small-pox patients seized with typhoid fever, and others during convales- cence from severe attacks of typhoid fever take small-pox. To those who object to vaccination, on the ground that since its intro- duction there has been an increase in the mortality from typhoid fever, I would remark, that as the infantile population (thanks to vaccination) is no longer decimated by epidemics of small-pox, the representatives of the children who used to die in childhood, grow up, to run the risk of all the diseases incident to adolescence and manhood, a circumstance which would explain why typhoid fever may perhaps be more frequent now than for- merly. Should the day ever come when we shall have the good fortune to dis- cover such prophylactics for measles and scarlatina as cow-pox is for small- pox, there will perhaps be people who in their turn will try to showr that measles and scarlatina are necessary maladies, the prevention of which occasions the development of new diseases. Such individuals would not be more mistaken than those whose theories regarding cow-pox we have now been refuting. If these gentlemen were logical in their reasoning, they would hold that CHICKEN-POX. 133 the more severe small-pox is, and the more copious the eruption, so much the more complete will be the depuration of the organism, and so much the better protected will the economy be from the diseases from which small-pox exempts ; consequently, that the confluent is the most desirable form of the disease ! It appears then, that no charge can be substantiated against cow-pox, that the verdict must be in favor of it as a prophylactic against small-pox, and that the discovery of Jenner must remain unchallenged as one of the greatest benefits conferred by medicine on humanity. The only reproach which can be adduced is that the prophylactic power of vaccination has in our day too often become unreliable, and is gradually diminishing. On that account, adopting in principle the opinion of Gregory, I would prefer variolation to vaccination ; but nevertheless, it is to the latter we must have recourse, for reasons which I laid before you when discussing the inoculation of small-pox. LECTURE IV. CHICKEN-POX. Chicken-pox, or Varicella, essentially different from Modified Small-pox.- Unlike Small-pox it does not protect from Variolous Contagion.-Small- pox does not protect from Chicken-pox.-Course and Characteristics of the Eruption. Gentlemen : If I concur with the general opinion of physicians in believing that small-pox and modified small-pox are identical, I am not at one with them as to the nature of chicken-pox, or flying small-pox [petite verole volante] as it is still very commonly designated. You will read in books, you will hear it said and repeated, that varicella is only a modification of variola; that chicken-pox and modified small-pox are identically the same disease; and that both are merely different forms of small-pox. You already know my opinion on this subject: with many others I hold that chicken-pox and modified small-pox are as much stran- gers to one another as small-pox is a stranger to measles; that they resem- ble one another as little as measles resembles scarlatina; and that they are as different as possible from each other in their symptoms, forms, and essential nature. And I will venture to affirm, that physicians who main- tain an opposite opinion have never taken the trouble to examine chicken- pox ; for if they had, they must have become convinced of their error. Chicken-pox looked at from a general point of view, as an abstraction deduced only from its anatomical characters, presents such sharply-marked differences from modified small-pox that it is difficult to understand how the two diseases should have been confounded. Then, on the other hand, we learn from the history of epidemics that chicken-pox can exist in an epidemic form by itself, whereas modified small-pox never prevails without being accompanied by normal small-pox. Again, the two diseases differ in respect of the age of the person for whom they have a predilection. Small-pox before the discovery of vaccination, and prior to the practice of variolous inoculation, while it chiefly attacked children, likewise attacked 134 CHICKEN-POX. adults, whereas chicken-pox was then as now almost limited to young sub- jects, not attacking adults, who had escaped it in their youth. As inocula- tion in England, Germany, and France, dates from last century, as vacci- nation was not in common use till the beginning of the present, cases of modified small-pox were very rare in those days: but at that time chicken- pox was perfectly known and described. Except in exceedingly rare ex- ceptional cases, small-pox does not attack a child vaccinated two or three years previously. You may with impunity inoculate such a child. But if you bring him into contact with another child who has chicken-pox, he easily takes it. From this fact alone, it is evident that chicken-pox is not small-pox. Again, if a person who has just had chicken-pox is brought into contact with a centre of variolous contagion, he ought not to contract small-pox if the chicken-pox of which the marks are still visible were the remains of modified small-pox; but nevertheless we have learned from experience that such an individual may quite well contract small-pox. The two exanthematous diseases may even go on simultaneously. Dr. Delpech, in a paper published in 1845, narrates the case of a child, who had had at the same time small-pox and chicken-pox. A person will never contract small-pox from being exposed to the con- tagion of chicken-pox. Will there be a similar immunity if you inoculate an individual with virus taken from the mildest possible case of modified small-pox? Again, small-pox presents itself under very variable forms, but chicken-pox is always the same in form and symptoms: in no case does an antecedent attack of small-pox exercise the slightest influence upon it. Moreover, while second attacks of small-pox occur only as excep- tional cases, second attacks of chicken-pox are far from being so uncom- mon. Do not all these considerations clearly prove that verolette-for this also is a name of chicken-pox-differs essentially from small-pox? The differences between the two diseases come out still more strongly when we examine them more minutely, comparing chicken-pox with mod- ified and with natural small-pox. In distinct small-pox, as I have reiter- ated on several occasions, the fever of invasion lasts for three days, and the eruption appears on the third: in modified small-pox, distinct or confluent, the period of invasion has the same duration as in the natural form of the disease. The course of chicken-pox is quite different. To-day, a child is seized with headache, feelings of general discomfort, and all the symptoms which accompany the onset of any fever; but on the very same day, before twenty-four hours have passed, there are visible on some part of the body -it may be on the face, back, abdomen, or legs-small slightly acuminated rosy spots, resembling the rosy lenticular spots of putrid fever. During the first twenty-four hours, from ten to fifteen such spots may be seen. The fever, nevertheless, continues. On the following day, from one hundred to one hundred and fifty spots may be counted: those of the previous evening have by this time elevated the epidermis, the elevations being generally in the form of blebs, which are sometimes rounded in the most perfect manner, and contain a serosity transparent like rock-water, and without any surrounding inflammatory areola. This description is quite inappli- cable to the natural variolous eruption: it is also inapplicable to the manner in which the eruption of modified small-pox appears in respect of situation, development, and form. The eruption of modified small-pox- unlike that of chicken-pox-bears no resemblance to a phlyctsena, a bleb of pemphigus, or to certain forms of herpes. These palpable anatomical characters are in themselves sufficient to establish categorically the differ- ences which so clearly distinguish the two affections from each other. Next morning, there is almost no fever, and it is observed that a new CHICKEN-POX. 135 crop of from one hundred to one hundred and fifty spots have appeared during the night. In the evening of this day, fever again sets in, and con- tinues till next day, when the spots of the previous evening have become blebs, and new spots appear (without indicating a preference for any par- ticular locality), in the situations where the eruption had already come out. Successive crops of eruption, and new onsets of fever, sometimes vio- lent, occurring during the night and ceasing during the day, are repeated for four or five nycthemera. The fever, therefore, has no resemblance to the variolous fever, which is continuous, and usually during a single par- oxysm brings out the eruption however generally distributed it may be over the body. After four or five attacks of fever, the eruption of chicken-pox is complete, and there is no more fever. The rosy elevations, which after from seven to ten hours were transformed into blebs, perfectly round, shining, and dis- tended, with lactescent serosity, in from twenty-four to thirty-six hours more increase in size, and become irregular in shape, like some of the pustules of ecthyma ; their serosity acquires an opaline appearance; and an inflamma- tory areola surrounds them. They remain in this state for about three days. Towards the third day, the serosity is replaced by pus : the pustule bursts : it is large, irregular, and painful. Thus, whilst from eight to nine days are required for the evolution of the variolous pustule, three nycthem- era are enough for the bleb of the chicken-pox. Farther, the variolous pustules are largest on the hands, but it is on the back and trunk that the varicellous pustules attain the greatest size. On the seventh day, the pustules of chicken-pox are dry, and in their place are to be seen blackish crusts like those which succeed the pustules of ecthyma, or red spots such as are presented by imperfectly healed blisters, according as they have proceeded more or less freely to suppuration, or have broken the skin like a blistering plaster of cantharides or ammonia. In chicken-pox, the eruption is in the form of blebs : in small-pox it is in the form of pustules. This important difference, irrespective of other distinctive characteristics drawn from the general symptoms, is quite suffi- cient to establish the non-identity of the two diseases. The following case, for which I am indebted to M. Dumohtpallier, fur- nishes me with additional evidence of the essential nature of the difference between small-pox and chicken-pox: " On Tuesday, 4th March, 1862," writes M. Dumontpallier, " I was called in to the family De R . The eldest of the daughters, between thirteen and fourteen years of age, had been only slightly unwell from the previous evening, but nevertheless, at my first visit on the 4th March, I observed a vesicular eruption on the face, arms, legs, and trunk. There existed slight lassitude, with some feeling of debility and pains in the limbs, a very little aching in the loins, no nausea, and hardly any fever. This young girl had beautiful vaccinal cicatrices. I diagnosed the case to be one of modified ■small-pox. The patient was soon restored to health ; but she will retain one or two pock-marks on the face. "On Saturday, 8th March, I vaccinated Miss De R 's two sisters, aged respectively ten and twelve, and also Mrs. De R and her brother, a young man of twenty-three. A vaccinal pock was developed on the arm of Mrs. De R , but in the two girls and the young man, the vaccination did not take effect. Matters remained in this state till Monday, 17th March, that is till thirteen days after the onset of the fever in the eldest of the three sisters, and nine days after the vaccination of the family, when I was sent for to see the two youngest sisters. I was told that both had had some feelings of discomfort on the previous day: during the day they had 136 SCARLATINA. taken a walk, but in the evening had begged to be allowed to go early to bed. Next day, the 17th, a very beautiful eruption of papules, which soon became slightly vesicular, appeared on the face, limbs, and back. On the following day, the blebs were filled with lactescent serosity, and soon dried up into the form of crusts. There was no severity in any of the general symptoms, and by the third day the appetite had returned. " I called in Professor Trousseau in consultation, who had no hesitation in saying that it was a case of chicken-pox. He came to this conclusion from the short duration of the period of invasion, the vesicular form of the erup- tion, the rapidity of the desiccation, and the small amount of constitutional disturbance. It is evident, from the facts just stated, in the first place, that the Misses De R were proof against the contagion of small-pox, for they were still under the protecting influence of a first vaccination ; and in the second place, that small-pox and chicken-pox are diseases distinct from each other in their nature and in their germ, as the Misses De R took chicken-pox, though proof against small-pox." Chicken-pox sometimes presents phenomena which are never met with in small-pox. Thus, in an epidemic of chicken-pox which prevailed in the Necker Hospital, the fever ceased when the malady began ; and during from fifteen to forty days pemphigoid blebs appeared on different parts of the body, leaving, on the surfaces which they had occupied, ulcerations exactly like those of pemphigus, which ulcerations continued for six weeks or two months. No such occurrences are ever observed in small-pox. To sum up: Epidemic conditions, general symptoms, the manner in which the eruption appears, and its form, all combine to establish the essen- tially different nature of chicken-pox and small-pox. Again, chicken-pox is never a fatal disease. No physician has ever seen a patient die of chicken- pox, though of course there may be a fatal issue from some complication independent of the exanthematous fever. This cannot be said of small-pox, nor of modified small-pox. Finally, the incubation of small-pox extends over nine, ten, or eleven days, as has been demonstrated in the practice of inoculation, whereas the incubation of chicken-pox is a period of from fifteen to twenty-seven days. Chicken-pox is not inoculable, or at all events my attempts to inoculate it have been failures: but when a child suffering from it returns to its family, we may prognosticate, from the teaching of expe- rience, that within from fifteen to twenty-seven days other children in the house will have taken the disease. LECTURE V. SCARLATINA. Variety in the Characters of Epidemics.- Contagion.-Incubation.- Compli- cations at the Beginning of an Attack.-Characters of the Eruption.- Desquamation. Gentlemen : It is now nearly six months since we have been fre- quently receiving cases of scarlatina into our wards. In town, it seems to be prevalent as a somewhat severe epidemic. You have here at present, an opportunity of judging for yourselves of the strange forms which this dis- SCARLATINA. 137 ease is apt to assume. I am unwilling to allow the opportunity to pass without bringing it under your notice, as it is a malady rather imperfectly known by hospital students. Scarlatina is more variable in its forms and symptoms than any other of the contagious exanthematous fevers; and its dangers are also more diffi- cult to foresee. Small-pox, whether distinct or confluent, mild or malig- nant, is always small-pox: its leading characters can always be recognized- always, except with a very few exceptions, chiefly observed by our prede- cessors-its external anatomical lesions being peculiar to itself, whether it be in its natural form, or modified, as it so often is, by vaccination or a pre- vious attack of small-pox. Scarlatina, on the contrary, may exist without showing itself on the skin; and when this is the case, the disease is not the less serious on that account. Measles always preserves pretty exactly its characteristic features: its diagnosis is usually, almost always, easy: its complications are generally foreseen, and occur at a certain stage, even on a particular day which the physician can predict. Scarlatina, as we shall see, presents complications which for the most part cannot be foreseen, and of which the most experienced practitioner can know nothing beforehand, even when they are imminent. Scarlatina is sometimes so very mild, that Sydenham, one of the greatest medical observers of past times, said of it: "Hoc morbi nomen (vix enim altius assurgit)." Sydenham gives us in his writings only the results of his personal experience, and as he had never seen severe scarlatina, he spoke of the disease with a sort of contempt which he was far from having for measles or small-pox. In our own day, some of the authors to whom we ought always to refer state, that for a long series of years the epidemics of scarlatina which came under their observation were so far from being serious that they were without fatal cases. Graves mentions that from 1800 to 1804 scarlatina ravaged Ireland, and was very fatal; while from 1804 to 1831, the physicians who had found it so terrible in 1800, 1801, 1802, 1803, and 1804, saw scarcely any fatal cases, so wonderfully mild had been the disease. But in 1831, an epidemic of malignant scarlatina broke out in Dublin and its vicinity: in 1834, it covered Ireland with mourning more extensive than that which was caused some years later by typhus, or than that which had been produced two years previously by the outbreak of Asiatic cholera.* At the commencement of my medical studies, when attending the clinic of Bretonneau, my illustrious master taught his class that scarlatina, which he had formerly heard spoken of as a very dangerous malady, was then a mild affection. He told us that from 1799 to 1822 he did not recollect having seen a single fatal case; and yet he had long practiced in the coun- try before he became first physician to the hospital at Tours. The numerous cases which he met with both in his hospital and private practice seemed at that time to have satisfied him that scarlatina was the mildest of all the exan- themata. But in 1824, an epidemic broke out in Tours and its environs: in less than two months Bretonneau learned that several patients had died with such frightful rapidity that-being opposed to the doctrines of Brous- sais then in repute-he blamed the treatment adopted by his colleagues, who bled most resolutely with a view to subdue the sore throat and the so- called inflammatory fever which attends the beginning of the attack. By and by, coming personally to close quarters with the disease, he found that he could not always successfully contend against it, and he saw it carry off * Graves: Logons de Clinique Medicale. Traduit par Jaccoud, 2me edition, T. i. Paris, 1863. 138 SCARLATINA. many of his own patients. The result was that Bretonneau, who had for- merly looked upon scarlet fever as a slight malady, now learned to regard it as equally mortal with plague, typhus, and cholera. Thus you see that during a quarter of a century, scarlatina appeared as an epidemic without showing any severity: then all at once it became changed in its manifestations, and cruelly smote all whom it touched. It is not usual for measles or small-pox to manifest themselves in this way. Very severe epidemics of measles and small-pox do, no doubt, sometimes occur, but as epidemics they never show such extremes of mildness and severity as scarlatina. Scarlatina is a disease which is more influenced than measles or small-pox by a dominating epidemic constitution, and hence it arises that an epidemic of scarlatina is sometimes very mild, and at other times very severe. You may have observed, gentlemen, with what care I have interrogated our patients with a view to ascertain the circumstances under which they contracted scarlatina. Causes which generally favor the appearance of other diseases have very little to do with the evolution of the exanthema- tous pyrexia?, and in respect of their causation, contagion ought to be the point most particularly inquired into. We shall afterwards have to return to the consideration of the evolution of contagion-germs. I should fear that I was doing injustice to this great question were I only to skim its surface : I should, through my own fault, be unable to make myself under- stood by you. You have seen how much importance I attach to ascertain- ing the day of first contact, direct or indirect, with a contaminated person or place. You have seen that proof of this contact was sometimes clear, and that at other times it was quite unattainable, and also that there were cases in which communication between the patients and persons with scar- latinous infection had been such as to make it impossible to determine the duration of the period of incubation. Nothing is more difficult than to state the exact time at which contagion has been contracted in an exanthematous fever, when the virus has not been directly introduced by inoculation; and, consequently, nothing has been more variable than the manner in which this question has been solved. According to some, the incubation of scarlatina varies in duration from three to five days, according to others it lasts for eight days, and some believe that it may be prolonged to fifteen, twenty, or even thirty days. In fact the figures given have been hypothetical. There exists an unwilling- ness to admit the fact that it is impossible to determine the duration of the period of incubation, just because it is impossible to fix the date of its commencement. Small-pox is the only fever in respect of which this date is determinable with precision, being the only one directly inoculable. In consequence of variolous inoculation having during half a century been practiced on a large scale throughout Europe, the time which elapses be- tween the moment at which the virus is placed under the skin, and that at which the malady declares itself, has been determined with precision. The rigorous determination of the length of the period of incubation in small- pox is dependent, therefore, upon its inoculability, a property which does not belong to any other exanthematous fever. From the non-inoculability of the other exanthemata, it has been necessary to assume as the beginning of the period of incubation, the moment at which the patient was first in con- tact with an infected person. But inoculation and contact are not the same thing. Here is a case in point! Five hundred sheep are collected together in the same park, or in the same fold; one of them takes the tag- sore, an eruptive disease of sheep, analogous to small-pox in the human species. Fifteen or twyenty days later, seven or eight other sheep are seized, SCARLATINA. 139 and on each succeeding day several more fall sick. It is sometimes four months before the entire five hundred have taken the disease. Now, these animals contracted the contagion at very different periods, although they were all shut up in the same place, breathed the same impure air, were together in crowded contact, and soiled by the discharge from the sores of the affected. Is there any reason to suppose that the period of incubation was longer in some of these sheep than in others? None: because if all the sheep had been inoculated simultaneously, the manifestation of the disease would have occurred in all without exception on exactly the same day. Inoculation and contact, then, are two very different things: by inoculation, the virus is introduced almost of necessity into the system; but by mediate or intermediate contact, the absorption of the virus, its conception-, if I may be allowed to use that expression, is not always secured-that only takes place when the economy is in a certain state of aptitude:-the way must be open, so to speak. When absorption has once taken place, whether after inoculation or contact, it is probable that the evolution of the disease occurs within a determinate time, which, within a few days or hours, is the same in all cases. Very well! Till we can inoculate scarlatina by the scarlatinous virus, we shall be as unable to determine the duration of its period of incubation as we are to determine the duration of the incubation of the tag-sore con- tagion in the different sheep constituting the flock of five hundred. In a family consisting of ten individuals, five weeks will sometimes elapse before scarlatina has attacked all the members, the case being quite similar to that of the flock of sheep. This neither arises from certain individuals having been free from contact for a certain time, nor from the period of incubation having lasted longer in some than in others, but from the difference in the respective aptitudes of the different subjects to receive the contagium. This is what we see take place with syphilis. When the syphilitic virus is scientifically inoculated, it determines, after the lapse of a certain number of days, the evolution of a specific vesicle, and the number of days is almost exactly the same in every case; but when several men have connection with the same infected woman, some will take the pox immediately, while others, after having been exposed on several successive days to the contagion, will not contract the disease till the last day, or perhaps not at all. This is explained by the fact, that those who at once contracted the disease from the first contact were in a physiological and pathological state suitable for the absorption of the virus, while the others were not in that condition of aptitude. To sum up: The duration of the period of incubation in scarlatina, that is to say, the time which elapses between the exact moment at which the morbid poison is absorbed, and the exact moment at which appear the first manifestations of the disease, cannot be rigorously determined in the present state of our knowledge. The same statement holds good in respect of measles. Under very exceptional circumstances, however, it is possible to attain considerable exactitude as to the duration of the period of incubation in scarlatina. In the beginning of the year 1859, I saw a very curious case which occurred in the practice of my friend Dr. McCarthy, who did me the honor of calling me in in consultation. A London merchant had taken one of his daughters to the Eaux Bonnes in the Pyrenees, and had passed the winter with her at Pau. On his way back to England he stopped at Paris, where he wished to remain some days. His eldest daughter was keeping house for him in London. Impatient to embrace her father and sister, she started for Paris. When crossing the Channel, she was seized 140 SCARLATINA. with fever and sore throat, and seven or eight days later arrived at Paris, in the middle of a very serious attack of scarlatina. She alighted at the hotel, almost at the very moment when her father and sister arrived from Pau. The two sisters remained together in the same room, and in twenty- four hours the sister who had come from Pau showed the first symptoms of a mild attack of scarlatina. In London, the disease was then epidemic; but there were no cases at Pau. This curious history proves that in scarlet fever the duration of the period of incubation is sometimes not more than twenty-four hours. I am, however, very far from believing that that is its ordinary duration. Although the period of incubation is limited with precision in small-pox, there is probably no similar exactitude of limitation in the other exanthematous fevers. The period of invasion in scarlet fever is quite as much without exact limits as the period of incubation. Recall to your recollection what takes place in small-pox. In normal small-pox, when the eruption appears within forty-eight hours of the first manifestation of symptoms, it may be affirmed that the case will be confluent, for, as a general rule, it is towards the end of the second day, or at the commencement of the third, that the pustules begin to come out in that form of the disease; and when the eruption does not appear till, the fourth day, the diagnosis is-distinct small-pox. In cases of confluent small-pox, it is very unusual for the eruption to be re- tarded till the fourth day, and it is as unusual in distinct small-pox for it to appear on the second. Observe, that I am at present only speaking to you of normal small-pox. I was on a former occasion careful to point out that in the modified disease the symptoms are different. In scarlatina, events do not proceed as in small-pox. In some cases, the eruption comes out during the first four or five hours of the fever, while in other cases there is no fever at the beginning of the disease, a fact men- tioned by Heister and other old authors, and which in later times has been repeated by various writers. Barthez and Rilliet state that in eighty-seven cases observed, the eruption was the first symptom of the malady in four cases: in the majority of the eighty-four cases, the fever of invasion lasted twenty-four hours, and rarely continued longer. It is still more unusual, except in complicated cases, for the eruption to be delayed beyond the second day, and very much more unusual for it to be retarded till after the third day. Some physicians believe that they have seen cases in which the* eruption did not appear till during the third day. I do not absolutely deny the possibility of such an occurrence, but I say emphatically that the occurrence is one of extreme rarity. My opinion is, that in the class of cases referred to, the eruption is often not recorded, because, though present, it has escaped observation, owing to its not having been looked for in the proper place. As a general rule, we first seek on the face for the eruption in exanthematous fevers, because, in point of fact, it first shows itself there in measles and small-pox; but in scarlatina the eruption does not come out first on the face. It generally appears first on the trunk, forearms, lower part of abdomen, and bend of the thighs, and may exist in these localities from twenty-four to thirty-six hours before it is visible on the face or neck. Under such circumstances, one might suppose that the eruption was only beginning to appear, when in reality it had been out for some time; but it is easy to avoid this mistake, if we are aware of the fact I have now men- tioned. There are, however, complicated cases of scarlatina, as of small-pox, in which the period of invasion is prolonged greatly beyond its ordinary term. It sometimes happens in seriously complicated cases of scarlatina that the exanthem does not show itself till as late even as the eighth day; as I SCARLATINA. 141 know from the following case. Six years ago, I was summoned by my honorable colleague Dr. Sarrazin to see a child of six or seven years of age supposed to have cerebral fever. He was complaining of headache, and had vomiting. We observed squinting, slowness of pulse, stupor, som- nolence. From these symptoms we believed that the patient was suffering from inflammation of the brain and its membranes. I saw the child again on the fifth, sixth, and seventh days without changing my diagnosis, and continued to give a very unfavorable prognosis. On the eighth day, there appeared a well-marked scarlatinous eruption, accompanied by the usual sore throat: from that time, the cerebral symptoms entirely ceased. I have not seen another case like this in the whole course of my medical experi- ence, but I know that similar cases have been observed by others. They are exceptional and very rare. As a general rule, I repeat, the period of invasion is very short in scarlatina. The symptmn which generally characterizes it is fever with or without previous rigors: in the last patients you have seen in the wards, these rigors were absent. The pulse is quicker than in the other exanthematous fevers. This is an important fact; for in studying the disease in its com- ponent parts, in speaking of scarlatina without eruption, we find that we often form our diagnosis solely from this extreme frequency of pulse, which is very rarely met with in other affections liable to be confounded with scarlatina. Diarrhoea and vomiting often accompany the fever of invasion. The sore throat almost always shows itself simultaneously with the fever: this is the symptom to which the patient first calls the attention of the physician, and it therefore takes a very important place in the diagnosis. The tongue has no characteristic appearance on the first day : it is febrile, that is to say coated with a somewhat slimy fur, and scarcely red at the point and edges. On the veil of the palate, however, there is already per- ceptible a rather bright redness, and sometimes a dotted appearance. This redness is very distinct upon the tonsils, which are slightly swollen. When the type of the disease is malignant, the symptoms assume a totally different form. There is a frequency of pulse still greater than in simple cases; and sometimes in adults from the first day of the fever, even before there is any appearance of eruption, the pulse is 130, 140, 150, or even 160. Disturbance of the nervous system at the same time super- venes, in the form of great restlessness, convulsions, invincible insomnia, and delirium, or at least a muttering delirium when the patient is left alone. Such symptoms are very unusual in simple sore throat or pyrexim other than scarlatina. From its first day, nay even from its first hours, malignant scarlatina makes itself known in all its malignity, and this malignity may be so intense as to carry off the patients within the first twenty-four hours. I was summoned by my friend Dr. Bigelow, to see a young American lady at a boarding-school near Paris. From morning, she had been in a s'tate of frightful delirium : she had incessant vomiting, intense fever, a pulse too frequent to be counted, and an extreme dryness of skin. On seeing the patient, I was led by these symptoms to pronounce the illness to be scarlatina ; and although there was nothing else to demonstrate its exist- ence, my diagnosis was confirmed by the presence of the characteristic scarlatinous eruption in another young girl in the same boarding-school where the disease was at that time epidemic. Our patient died before the close of the day. In 1824, at the commencement of that disastrous epidemic which deso- lated Tours-and of which I have already spoken-I saw, along with Bre- tonneau, a young woman die in eleven hours with symptoms of the most 142 SCARLATINA. terrible description-delirium, excessive agitation, and an extraordinary acceleration of pulse. There was nothing else to indicate the nature of the disease, except that we were then in the middle of an epidemic of scarla- tina, and that several members of this young lady's family had taken the disease. Under similar circumstances, during an epidemic of scarlatina, particu- larly when the disease has already attacked persons in immediate commu- nication with your patient, be very guarded in your diagnosis, if the case present cerebral symptoms. Be specially guarded, if such symptoms declare themselves at the beginning of the illness, as they then almost always announce that the malady is malignant scarlatina, which with very few exceptions proves rapidly fatal. I must insist upon this point, as inatten- tion to it will cause most serious errors of diagnosis, and give rise to mistakes in prognosis exceedingly injurious to the reputation of the physician. People forgive us more easily for allowing our patients to die, than made a mistake as to the issue of an illness. The very great importance of these precepts has been emphatically proclaimed by Hippocrates in his first chapter on prognosis.* He says: " To my mind he is the best physician who knows beforehand what is going to happen. By penetrating into, clearly describing the present and the future of the maladies of his patients, and explaining symptoms which they omit to state, he will gain their confidence. Convinced of his superior intelligence, they will unhesitatingly place themselves under his direction. It is impossible to restore every patient to health, but the prediction of the succession of symptoms will be even more highly appreciated. It is of importance to recognize the nature of similar affections, to know the extent to which they exceed the constitutional power, and likewise to discern where there is any supernatural element in the disease; for that is a point which affects the prognosis. It is in this way that the physician will obtain the merited meed of admiration, and practice his profession with ability. Knowing the cases which are curable, he will be the better able to guard his patients from danger, by indicating the precautions to be taken against each untoward contingency: and by foreseeing and predicting fatal and favorable issues, he will escape blame." Such are the considerations which ought always to be present to your minds, and the full import of which you already understand. But to return to our subject: when, during an epidemic of scarlatina, you meet with the formidable symptoms of which I have now spoken, give your opinions with reservations, for the cases may perhaps terminate rapidly in death. Similar fatal symptoms almost never show themselves thus unex- pectedly in measles or small-pox. The temperature rises to a higher point in scarlatina than in any other eruptive fever. The skin of the patient communicates to the hand a sensa- tion of the sharpest and most pungent heat. The thermometer placed in the axilla sometimes rises to forty-two or forty-two and a half degrees, which is the highest temperature ever observed in disease. The fever con- tinues moderate, and the heat inconsiderable during the prodromous stage, but about twenty-four hours prior to the eruption, the temperature rises suddenly to a high point, at which it remains during the development of the exanthem. The maximum of the eruptive process corresponds exactly with the maximum of temperature: this is the feverse of what occurs in small-pox, in which there is a diminution of temperature proportionate to the evolution of the exanthem. In scarlatina, the abatement of heat, in * Hippocrate : (Euvres Completes. Trad. Littre. Paris, 1840, T. ii, p. 111. SCARLATINA. 143 place of being rapid as in small-pox, is gradual, steady, without exacerba- tions, and is not completed till from four to eight days have elapsed. I have endeavored to point out to you at the bed of the patient, the char- acters of the eruption, but I fear that I have not succeeded, notwithstand- ing the careful manner in which I have proceeded. Upon consulting certain books, one might suppose that it was impossible for a physician to have any scope for hesitation in the differential diagnosis of eruptive fevers. Measles is an eruption of small, isolated, irregular spots, with blank inter- vals between them. Small-pox is recognized by its small acuminated papules, which on the second day become vesicular; on the third, pustular; and about the eighth, umbilicated and surrounded by an inflammatory areola. These features are so well marked, that they cannot be mistaken. As to scarlatina, we are told that its characteristics are still more precise: it is a diffused scarlet redness of the skin occurring in patches. This is all very simple, but the description is far from an accurate account of what is seen in all cases. Indeed, I have shown you cases of measles in which the eruption was diffuse and uniform, without intervals of unaffected skin. Such cases are certainly exceptional; but still there are such cases. On the other hand, we meet with cases of scarlatina, both distinct and confluent, with the eruption in some places in patches, or in numerous small, red, rounded points, perfectly isolated from each other, and devoitl of that winy rasp- berry hue generally attributed to it: though differing in appearance from measles, it may be mistaken for that eruption. The eruptions most com- monly mistaken for scarlatina are those to which I have already called your attention, as pretty frequently occurring at the beginning of attacks of small-pox, particularly of modified small-pox, and to which the epithets scarlatiniform and morbilliform have been applied. Scarlatina is distinguished, at the first appearance of the eruption, from other eruptive fevers, by the redness of the skin being often accompanied by the millet-seed rash, which is almost invariably met with when the scar- latinous rash is confluent in ever so small a degree. The miliary eruption shows itself on the sides of the neck, on the chest, and on the lower part of the abdomen: it can be detected without being seen, by passing the hand over these parts, from the little inequalities communicating the sensation of what is called goose-skin. When the inequalities are examined by the eye, a multitude of small vesicles are seen, which, at the end of thirty-six or forty-eight hours, are filled with a lactescent fluid. The scarlatinous eruption itself is not really constituted by one uniform blush as in erysipelas, but by an infinite series of small red elevations of the skin resembling the vesicles of a very closely placed eczema. The elevations can be recognized by the touch, and the correctness of their description now given can be verified by using the magnifying glass. It will also be seen that the small elevations rest upon a rosy basement. The intensity of the redness of the skin is greatest on the neck, chest, abdomen, and internal aspect of the arms and thighs. When strong pressure with the finger is made on the parts occupied by the eruption, or when a pencil is drawn over the skin, as if to mark a line, the redness gives place momentarily to a white line across the red; on the removal of the pressure the redness rapidly reap- pears. This fact did not escape the notice of our predecessors, and you will find it clearly stated by Borsieri. The eruption comes out everywhere pretty nearly at the same time, but is generally visible on the neck and chest before it shows itself on the face. The character which it presents on the face and trunk is similar; it is streaky, with a bright red in some places along- side of white streaks: on the face, which is swollen, the skin seems as if it bore the marks of a smart slap with the fingers of the open hand: there is 144 SCARLATINA. swelling of the hands and feet, as well as of the face. The swelling, which shows itself with the eruption, also increases along with it, and is therefore most conspicuous about the second or third day. The tumefied condition of the hands is very obvious to the sight, impedes the movement of the fingers, and prevents the patient from closing the hand. The swelling keeps pace with the eruption, and generally disappears at the same time from the face and extremities. The swelling I am now speaking of must be very carefully distinguished from scarlatinous rheumatism, which I shall have forthwith to bring under your notice. When we look at the patient's throat we find that it is of a bright red color, and that the veil of the palate and tonsils are swollen; the latter very often present small whitish concretions, the earliest manifestation of the membranous sore throat of scarlatina. The aspect of the tongue, already described, is so essentially specific, that it is in itself sufficient to enable one to recognize the existence of scarlatina. Nothing like it is ever met with in measles or small-pox. It is as specific in scarlatina as are pustules on the mucous membrane of the mouth in small- pox. On the first day there is only a slimy fur, more or less thick, more or less white, and which, if the patient has vomited, has a yellow or green color: at the point and edges there is only a slight redness. On the second day the redness increases in intensity and in extent: and this change con- tinues to proceed on the third day. About the fourth or fifth day the saburral coating has almost or altogether disappeared: the whole tongue is then scarlet and swollen, and the papillae rise above the level of its surface in such a way as to give it a strawberry-like aspect. This appearance is produced by the tongue being denuded of its epithelium: we can sometimes see this desquamation in progress, and can even accelerate it by gentle rub- bing with a bit of linen cloth. This is a constant phenomenon in scarlatina, except when there is an absence of fever; and nothing like it is met with in measles or small-pox, even when in the latter there is stomatitis. About the seventh or eighth day the tongue, whilst it retains its red color, becomes smoother: about the eighth or ninth day the restoration of the epithelium commences very perceptibly, being at first exceedingly thin, then of the thickness of onion-peel; and about the twelfth day it has nearly regained its normal thickness, but the mucous membrane still remains redder than natural. In studying the relation which the severity of the disease bears to the intensity of the eruption, it becomes obvious that some authors have in respect of this subject fallen into a capital error liable to lead astray those prac- titioners who are not familiar with scarlatina. These authors say that when the eruption is full-blown, bright, and well come out (to use the common phrase), the patient is in less danger of serious complications. The opposite of this position is the truth. In scarlatina, as in small-pox, the more intense the eruption, in the same ratio, the more severe is the disease. In non-con- ffuent scarlatina the danger is usually less than in confluent, just as the danger is less in distinct than in confluent small-pox. In both of these exanthematous fevers, in proportion to the intensity of the eruption is the severity of the symptoms and the peril to the patient: this proposition is established by what has been seen in the course of epidemics, and you have an opportunity of verifying it for yourselves by the observation of patients in the wards. The proposition, however, is not absolute. In scarlatina, as in small-pox, if the eruption is checked by some serious antagonistic deter- mination, by profuse hemorrhage, by great disturbance of the nervous sys- tem, it comes out badly and incompletely. Scarlatina, as I said in beginning my lecture, is not always like itself; it SCARLATINA. 145 is identical in its essence, but very dissimilar in the forms which it assumes. In some cases, after ten or twelve hours of fever, an insignificant eruption appears on the neck and trunk, and in two or three days the slight febrile excitement by which it was accompanied disappears, the patient having scarcely experienced any discomfort. Desquamation proceeds by small stripes or patches, and sometimes in a manner hardly perceptible: in five or six days more the patient is restored to perfect health. If he avoid ex- posure to cold, and other acts of imprudence, the whole affair is at an end. The malady has been of so simple a character that it might have run its course unnoticed. Between the very mild and the very Severe, the two forms which I have had principally in my eye when sketching the leading features of the dis- ease, all intermediate forms are met with ; and there is besides that terrible scourge, malignant scarlatina, than which no pestilential disease is more formidable. Desquamation in scarlatina is not very well understood by the majority of physicians. This morning I showed you two women, in one of whom, though at the seventy-second day, it is still going on: in the other, at the thirty-fifth, it is in full activity. The red color of the skin generally dis- appears with greater or less rapidity before desquamation commences, but it begins sometimes in various parts of the body while the eruption is still visible. It begins on the neck and chest between the sixth and ninth days: it then proceeds on the limbs, then on the hands (first on the back and then on the palms), and last of all on the soles of the feet. On the whole body desquamation presents special characters, but they are more distinctly marked on the hands and feet than elsewhere. On the trunk the scales are tolerably large, often, it is true, not being more than two or three millime- tres in breadth, but at other times measuring from one to two centimetres. On the arms and legs, where the epidermis is a little thicker, the desquama- tive plates have sometimes a size of four or five centimetres, and they can be stripped off in broad bands, as is the case after erysipelas and inflamma- tion of the areolar tissue. Scarlatinous desquamation never assumes the furfuraceous form, as in the desquamation which follows measles. In measles the bran-like scales are so small that unless you look at them very closely you cannot see them, and it even often happens that this white, dry epider- mic dust, resembling flour in appearance, is only observable upon brushing the skin of the patient with the sleeve of the coat. In scarlatina the des- quamation of the hands and feet has too significant an appearance to be mistaken. The epidermis peels off in irregular flakes, variable in size, and sometimes very large, like pieces of a glove. From the feet, where the pro- cess goes on most slowly, the detached flakes are still thicker than those which come off the hands, and in some cases the nails, which as you know are prolongations of the epidermis, fall from the toes. This is a rare occur- rence, but it has been observed, and one example of it is recorded by Graves. ' In concluding my remarks on the subject of desquamation, let me add that Wunderlich has observed a considerable elevation of temperature dur- ing the process. This is not what we should expect, and is the reverse of what we meet with in small-pox. To me it seems to prove that the fever is far from being ended when the more palpable symptoms of the disease have ceased; and as the morbific action is not completely exhausted, one can to a certain extent understand the development of those formidable complications which insidiously supervene during this period, and of which I shall have much to say by and by. VOL. I.-10 146 SCARLATINA. Cerebral and Nervous Complications.-Sore Throat, Complicated with Diphtheria.-Buboes.-Rheumatism. The most striking as well as the most alarming phenomena in scarlatina are the nervous symptoms which are liable to occur. Their intensity is a peculiar feature in this disease, and in most cases they suffice to establish the diagnosis between it and the other exanthematous fevers. We hardly ever meet with serious cerebral disturbance in the beginning of an attack of measles or small-pox, with the exception of epileptoid convulsions, which are not very unusual at the onset of both of these diseases, particularly in children; but as ultimately, when the eruption appears, there is not even a possibility of any confusion except between measles and scarlatina, the in- tensity of the nervous symptoms in the latter constitutes the capital circum- stance which determines the differential diagnosis. In scarlatina, nervous symptoms set in from the very first: during the first day there is delirium. I am now speaking of what takes place in the severe forms of scarlatina, for in the mild forms, we only meet with dis- turbance of the nervous system in exceptional cases. In very severe scar- latina, delirium seldom fails to occur, and in the worst cases, it is as formidable as in typhoid fever of the most aggravated type: it declares itself simultaneously with the appearance of the exanthem, and often con- tinues up to the period of desquamation, or, to speak more correctly, till the subsidence of the fever. There are other forms of nervous disturbance met with in scarlatina, besides those which are indicated by the terms carphologia, jactitation, coma, and coma vigil. In a word, we meet with every form of typhic nervous disturbance. And in children, we also meet with epileptoid convulsions during the first two or three days of the disease, but less frequently than at the beginning of attacks of measles and small-pox, when, as I have al- ready remarked, they are not uncommon. But convulsions in scarlatina have a much more serious import; for whilst they are considered by some authors (among whom is Sydenham, from whom in this I dissent), when occurring in small-pox as a favorable omen, and are generally looked on as having only a moderately unfavorable influence on the prognosis in the onset of measles, they always indicate considerable danger when they occur during the first or second day of scarlatina. They indicate still greater danger when they occur in the third stage of the disease, in connection with general oedema. I shall afterwards have to explain what they then imply, and to point out that they are almost invariably followed by a fatal issue. Even in adults there are examples of epileptiform phenomena. They occur about the second or third day of the disease, and principally in individuals subject to true epileptic seizures. These convulsions recur, they are followed by coma, and death may close the scene within twenty- four hours from their first manifestation. Dyspnoea is another nervous complication which is important, and of sinister presage. The difficulty of breathing of which I speak is quite un- connected with any appreciable lesion of the lungs, and in this respect, as well as in the sadness of its meaning, resembles the same symptom so often met with in many septic diseases, in puerperal typhus, in camp typhus, and in cholera. You saw a terrible example of this kind of dyspnoea in a recently delivered woman who was carried off by scarlatina with fearful rapidity, and the history of whose case I shall recall to your recollection, when we come to consider the subject of treatment. Besides the nervous symptoms dependent upon disturbance of the cere- SCARLATINA. 147 bral and spinal systems, there are others originating in the ganglionic sys- tem which I must now mention : and among which probably is the alarm- ing dyspnoea I have just been speaking of. Every one is acquainted with Claude Bernard's remarkable inquiries into the functions of the great sym- pathetic nerve: all know that when this nerve is divided, the parts to which its branches are distributed are not paralyzed, but on the contrary manifest increased functional action in augmented calorification and secretion. The scientific professor of the College of France has shown that on cutting on one side the branches of the sympathetic which are distributed to the ear and face of the rabbit, the temperature of these parts rises to four or five degrees Centigrade above the normal temperature, and above that of the corresponding parts of the opposite side where no section has been made. He has shown that by destroying the thoracic ganglia and the ganglia of the solar plexus, effects of increased vascularity are produced similar to those seen in the experiments just mentioned, and causing violent inflam- mation : he has also shown that the secretions are greatly influenced by the ganglionic system. Applying to pathology the results of the physiological experiments, we come to the conclusion that when there is abnormal in- crease of temperature in an animal, there is more disturbance of the sym- pathetic than of the cerebro-spinal system. Now, there certainly is no dis- ease attended by so great a general elevation of temperature as scarlatina. When the Centigrade thermometer is placed in the axilla, or is introduced into the rectum of scarlatinous patients, it marks forty or forty-one degrees. Dr. Currie has even noted 112° Fahrenheit, which is equivalent to forty- four and a half degrees Centigrade. This increase of temperature can only be explained by a great disturbance and a very impaired power in the gan- glionic system, a condition at the same time indicated by disorder in func- tions under the influence of the great sympathetic, as manifested in inces- sant bilious vomiting in the beginning of the disease, lasting sometimes for four, five or six days, and in intractable profuse diarrhoea which I have often seen. It is essential to bear in mind that these morbid symptoms are not of an inflammatory character. If, under the influence of the notion that the dry burning skin is a proof of the presence of inflammation, we treat the vomiting and diarrhoea by antiphlogistics, we pursue the most pitiable and perilous course we could adopt. Of all the eruptive fevers, scarlatina is that which least demands the employment of antiphlogistics, a mode of treatment, which is also rarely beneficial in small-pox or measles. There remains another complication to be noticed, viz., hemorrhage from the mucous surfaces, and into the subcutaneous cellular tissue. When there is from the beginning of the attack a hemorrhagic tendency, death is invariably the issue; while hsematuria when observed, as it frequently is, in the course of the disease, and in conjunction with anasarca, is a much less evil omen. You have seen several patients restored to perfect health after having passed bloody urine for more than a fortnight. We shall after- wards return to this subject. The sore throat of scarlatina is the next topic which presents itself. It is very difficult to understand well and describe well this affection. It seems, in general, sufficiently easy to point out its simple and its serious forms; but in respect of the latter there is one form, which in its turn we shall have to study, in which this facility does not exist-a form in which diphtheria probably intervenes as a complication, to contradict the antici- pations of physicians, and to impart to the sore throat a character of the most alarming severity. I have already established that the sore throat is an essential part of scarlatina. It is very rarely absent, even in the 148 SCARLATINA. mildest cases, just as it is very unusual for measles, however mild, to be unattended by pain in the larynx. Sore throat is also met with in small- pox, for three or four pustules on the pharynx are quite enough to produce it; but there is a very marked difference between variolous and scarlatin- ous sore throat. In scarlatina, from the first day of the attack, as I have already said, the veil of the palate has a red hue, analogous to, but deeper than, that of the skin: the tonsils are swollen, and of a purple color. The fever con- tinues its course, and after from two to four days, there often appear on one and sometimes on both tonsils small whitish concretions, generally of a milky whiteness, unless the patient has vomited, when they may be stained by the ejecta from the stomach. In minutely examining them, and raising them up with the handle of a spoon, we find that they differ from diphtheritic false membranes. The latter are generally yellowish- white, adherent to the tonsils, and when seized with the forceps generally peel off in strips: the concretions are pultaceous, less adherent to the tonsil which they cover, devoid of the character of false membrane, and much more resemble the secretions which form on the surface of ill-conditioned ulcers. In point of fact, they are nothing more than a compound of epi- dermis and sebaceous' matter produced by the tonsil, and not at all a pseudo-membranous secretion. Dr. Peter, indeed, has shown that the characteristic feature of pultaceous sore throat is an exaggerated produc- tion of epithelium, which by desquamating rapidly gives rise to the fibrin- ous-looking deposits. It is an affection, therefore, which has no relation to diphtheria.* As the progress of the affection advances, its intensity may become so formidable as to embarrass both respiration and deglutition, but especially the latter. The drinks which the patient takes are returned by the nose, and the voice becomes nasal. The cervical glands, particularly those at the angle of the jaw, are swollen. Without any medical intervention, or under very slight treatment, this kind of sore throat begins to abate in severity as the disappearance of the cutaneous scarlet eruption commences. The tonsils throw off the concretions, which leave behind them a red and sometimes excoriated surface; and the affection is cured. The throat and tongue, however, remain susceptible, and this increased sensibility is more persistent in the former than in the latter. This condition ultimately ceases after a sort of desquamation analogous to that which we see take place on the tongue. Such is the common, and simplest, form of the sore throat of scarlatina. I have already told you that there are other more serious forms ; and one of them, to which I have already referred, is according to my experience almost invariably fatal. To that form of sore throat I must in a very special manner direct your attention. Some individuals have scarlatina in a medium degree of severity: there is a little delirium at night, and scarcely any other nervous symptoms: the pulse is rapid ; the pain in the throat is moderate. On the eighth or ninth day of the attack, recovery seems a certainty : the fever has subsided, the eruption has disappeared, and the family has ceased to be anxious. In this propitious state of the case, swelling suddenly appears at the angles of the jaws, which not only takes possession of that situation, but extends to the neck and sometimes to part of the face : a sanious fetid fluid flows profusely from the nasal fossse: the tonsils become very large: the breath exhales an intolerable * Peter (Michel) : Article " Angines" in the Dictionnaire Encyclopedique des Sciences Medicales, T. iv, p. 707. SCARLATINA. 149 smell: the pulse becomes small and suddenly regains its rapidity : the delirium reappears, and other nervous symptoms occur. Then, the delirium continuing, coma supervenes: at the same time, the skin becomes cold, the pulse acquires a more and more miserable character, and after three or four days of this state, the patient dies, sometimes sinking slowly, and at other times being carried off suddenly as if in a faint. How are we to explain what has taken place ? Has diphtheria super- vened to complicate the scarlatina, and divert it from its proper course ? The symptoms bear so strong a resemblance to the terrible forms of that frightful disease which carry off both adults and children before the affec- tion has extended to the larynx, the false membranes still remaining local- ized in the nasal fossae, ears, and throat-the symptoms so much resemble the rapidly fatal forms of diphtheria, that one is induced to believe that the case is no longer one of scarlatina, but that the other dreadful scourge has come to destroy the patient. I am the more disposed to adopt this view, as under certain circumstances the larynx is invaded. Graves cites cases of persons dying of croup at the end of an attack of scarlatina, and also of persons recovering from the exanthematous fever after having dis- charged false membranes of tubular shape, moulded in the trachea. In mentioning theses cases, Graves calls me to account for having mistaken this form of scarlatinous sore throat; and in proof of my having committed a mistake, he quotes my expression-"Scarlatina does not like the larynx." During my period of service at the Children's Hospital, I so often found such an extraordinary identity between the sore thoat of malignant scarla- tina and the sore throat of malignant diphtheria, that I became shaken in my opinion. At present, I cannot prevent myself from believing, though I dare not affirm it as a fact, that the symptoms now under consideration depend upon a complication with a formidable form of diphtheria occur- ring at the close of the attack of scarlatina. The patients certainly sink with all the symptoms of diphtheritic poisoning, such as a lowering of the general temperature, a small pulse, a fetor of the breath exhaling from mouth and nose, and a general paleness of the skin, a combina- tion of symptoms not met with in any other serious disease. We can sup- pose, then, that in persons placed under certain conditions, as for example in a centre of epidemic diphtheritic influence, such as is, one may say, always dominant in hospitals for children, the scarlatinous sore throat may become the starting-point of a diphtheritic attack, exactly in the same way that a small excoriation behind the ear, an ulceration of the vulva, or any other solution of continuity existing in persons in the midst of erysipela- tous epidemic influences, may become the starting-point of erysipelatous manifestations. A circumstance which tends to support me in looking at the facts from this point of view is this-that I can only recollect one case of recovery from sore throat supervening suddenly at the ninth or tenth -day of an attack of scarlet fever. The patient who made this recovery was the daughter of my honorable friend Dr. Caffe. Now, in true scar- latinous sore throat, even of a serious character, beginning with the exan- thematous fever, and reaching its maximum intensity on or between the fifth and eighth days of the disease, recovery is the rule, and generally takes place without the assistance of art. When we come to consider the treatment of scarlatina, I will speak of the treatment of scarlatinous sore throat: in the meantime, I will only remark that membranous scarlatinous sore throat runs a very different course from diphtheritic sore throat. Observe, I am not now alluding to the malignant scarlatinous sore throat, to which I directed your attention, but to the simple form of the affection, which, as I have already said, is 150 SCARLATINA. almost always accompanied by pultaceous concretions. The diphtheritic affection has a tendency to spread to the nose and larynx, but the scarlati- nous sore throat generally remains confined to the pharynx, and notwith- standing Dr. Graves's condemnation of the proposition, I still maintain, that scarlatina has no liking for the larynx. True scarlatinous sore throat, then, is pharyngeal, differing in this respect from the sore throat of mea- sles, which is laryngeal, and from that of small-pox, which is both pharyn- geal and laryngeal. The voice of scarlatinous patients, when affected, is snuffling, but its tone is sonorous : the voice does not undergo the modifi- cations to which it is subjected in the other form of sore throat, when trav- ersing the throat, nose, and mouth. In measles, it often happens, that the tone of the voice, very much altered during its formation in the larynx, undergoes no farther change in traversing the back part of the throat. In describing the eruption, I noted that the swelling by which it is ac- companied impedes the movements of the fingers and toes; but a congested state of the integuments is not the sole cause of the complaints which the patients make of this description of embarrassment: it may also be depend- ent upon rheumatism, another complication of the acute stage of scarlet fever. Scarlatinous rheumatism is, at least in adults, a very common epiphenom- enon, and we have at present two patients suffering from it. The nature of the affection is often mistaken from' the absence of the general symptoms of ordinary rheumatism, and from the rheumatic manifestation being con- fined, in the majority of cases, to three or four joints, particularly to those of the h$nd and wrist. The patients complain of very little else, and unless attention is directed to this particular condition, its existence may remain unnoticed. By minute interrogation, by carefully examining and applying a certain degree of pressure to the joints, articular pains are found to be present in perhaps a third of the cases. It is important to know this; for acute affections of the joints, general arthritis, pericarditis, and endocarditis frequently occur during the course of the disease. Graves has called atten- tion to these complications. I have observed them. They seem to be of the nature of rheumatism. St. Vitus's dance is sometimes, in children, a consequence of scarlatinous rheumatism. I shall return to that subject. Engorgements of the glands, true scarlatinous buboes, occur sometimes towards the close of 'an attack of scarlatina, about the decline of the erup- tion. They are met with in different situations, but chiefly in the neck. All pestilential diseases are accompanied by buboes. For example, dothi- enteritis has its mesenteric buboes: for as you are aware, about the ninth or tenth day of that disease, the mesenteric glands may become so enor- mously large as to equal in size the egg of a pigeon. Scarlatina, which is likewise a pestilential disease, has also its buboes. The cervical region is their principal seat, and their evolution is contingent upon the lesions of the throat. From the very beginning of the disease, swelling of the glands is observable in both sides of the neck and at the angles of the jaw. Some- times the cervical glands suddenly become the seat of inflammation, about the tenth or twelfth day, independent of the effects of the severe form of sore throat of which I have spoken. The skin becomes red and tense, and in four, five, or six days, there is formed an abscess of greater or less size, from which, if opened, pus issues. The cellular tissue surrounding the glands is in some cases sphacelated. I recollect a lad of fourteen years of age, in whom the gangrenous condition was so extensive that the muscles of the neck were dissected, as occurs in diffuse phlegmonous inflammations, showing the carotids pulsating at the bottom of a horrible wound. The patient recovered, but a hideous deformity remained as a consequence SCARLATINA. 151 of the gangrenous destruction of tissue. A similar case is described by Graves. Analogous lesions may occur in parts of the body where there are no glands, or at least where they do not seem to have been the starting-point of the mischief. In the lad whose case I have just detailed, besides the great abscess in the neck, a diffuse phlegmon appeared in the leg, on the tenth day of the attack of scarlatina: it caused considerable shortening of the tendon, and left such an amount of permanent lameness as was sufficient to exempt him from military service, when he was drawn in the conscrip- tion six or seven years afterwards. Scarlatina may cause, not only glandular engorgements, acute buboes, and diffuse phlegmonous inflammation of the cellular tissue during the active period of the disease, but likewise chronic engorgement of the glands. In children untainted with scrofula, we meet with chronic glandular en- gorgements dating from the beginning of the attack of scarlatina, and con- tinuing two, three, or four months after recovery. In persons of strumous diathesis these engorgements become king's evil [ecrouelles], and in them the inflammation of the glands often terminates in scrofulous ulceration. Complications occurring during the Decline of the Disease.-Anasarca.- Hcematuria.-Albuminuria.-Convulsions.- (Edema of the Glottis.- Pleurisy.-Pericarditis.-Endocarditis.-Rheumatism.-Scarlatina with- out Eruption.-Anasarca without Eruption.- Treatment. We have still to study, on the one hand, the complications which super- vene during the period of the decline of scarlet fever; and on the other, to consider the disease in its rudimentary forms, by which term I am far from meaning its simple forms, but the forms which it assumes when its usual characteristics are absent, when it is, as in many cases, so disfigured that we cannot recognize it except by the exercise of an exceedingly minute atten- tion. This is undoubtedly the most important part of the history of scar- latina-less important, however, from a nosological than from a practical point of view. The complications of the period of decline may be divided into two groups; first, the immediate; and second, the mediate, or those which occur much later than the immediate. In the decline of the disease, we may still meet with nervous complica- tions. An individual recovers from scarlatina: he is convalescent, and you have ceased to be anxious about him, when fits of vomiting suddenly occur, like those which ushered in the original seizure: the vomiting is accompa- nied by delirium, alarming restlessness, and great frequency of pulse, the patient ere long dying comatose or in convulsions. Nevertheless, there is ■an absence of anasarca, albuminuria, hsematuria, and of everything which could lead one to anticipate the symptoms just enumerated. Complications of this kind are met with in adults as well as in children. Occurring during the wane of the disease, they have a much more unfavorable mean- ing than when they appear in the first stage, though they are then of very serious import. I cannot, therefore, too often repeat, that we ought not to look upon patients as recovered from scarlatina till long after the cessation of the last of the morbid phenomena. There is no other disease which so greatly foils the physician, and so completely throws him out in his calcu- lations. The fever is at an end, and there is nothing wrong to be seen ex- cept some symptoms which in appearance are very slight. You state that recovery has taken place; but nevertheless the malady may remain uncon- 152 SCARLATINA. quered, and may carry off the patient with great rapidity at a time when there no longer seemed anything to fear. Anasarca is one of the immediate phenomena of the wane of the disease which ought most particularly to engage our attention. It is met with in cases of medium severity, rather than in those of the most serious forms of scarlatina. It not only occurs in convalescent patients who have been ex- posed to cold, who have committed some imprudence, such as an error in diet, but even in those who have been constantly surrounded with every possible care, and watched with unremitting solicitude. MM. Barthez and Rilliet have noted that this symptom wras present in one-fifth of their cases. It never appears till fifteen or twenty days after the eruption, and I have seen it supervene a month after the eruption was entirely gone. Anasarca generally sets in suddenly. It invades the face, and every part of the body. It sometimes happens that a child whom, at our evening visit, we left lean and wretched-looking, appears quite plump on the morrow, in con- sequence of turgescence caused by infiltration of the subcutaneous cellular tissue. This turgescence sometimes attains its maximum in twenty-four hours: it is generally universal, and much greater in degree than when the anasarca is dependent on organic affections of the heart, or on Bright's dis- ease. But there are cases in which it shows very little, and is limited to the face and extremities. The anasarca is associated with a remarkable paleness of the skin, and is almost always preceded or accompanied by heematuria. Hcematuria is in point of fact a rather common occurrence in scarlatina, although it frequently escapes observation. If the blood passed is pure, or only slightly altered by admixture with the acids of the urine, which has then a black color, the sanguineous character of the urine is recognized and pointed out by the persons in attendance on the patient; but it is not ob- served when, from the quantity of blood being less, the urine is rose-colored. The tint of bloody urine may be as greenish as whey, which has a tint essen- tially different from urine in Bright's disease, as well as from every other description of urine. During the first few days, the hsematuria may be so great as to enable one to see blood at the bottom of the urinal, and on pour- ing the urine into a test-tube, there will be perceived a precipitate of blood- globules occupying one or two centimetres. The liquid resembles a strong solution of rhatany. As the affection progresses, the urine assumes the color indicated by this comparison, but the presence of blood can still be ascertained by finding altered blood-globules adhering to the sides of the test-tube, as well as by an enormous quantity of albumen being contained in the urine. When the urine is heated, and treated with nitric acid, we do not obtain a white albumen as in Bright's disease, but an albumen which is either of a brownish hue, or slightly stained in color like that which we meet with in acute albuminuria. Albuminuria-this acute albuminuria, generally transient, and in the majority of cases disappearing at the end of a fortnight or three weeks, sometimes even more rapidly, may pass into a chronic state, and become real Bright's disease. The acute symptoms have disappeared, and the econ- omy seems to have returned to its normal state; but notwithstanding, on examining the urine from time to time, we find that it always contains albu- men. When it is persistent in the urine for a month or six weeks, the symptom is very unfavorable. It shows that the kidney has begun to be infiltrated with fibro-plastic deposit, and that, sooner or later, the patient will sink under the progress of the new complication. Anasarca, like the transient albuminuria which it accompanies, and to which it is related, is generally, but particularly by children, quickly got SCARLATINA. 153 rid of with the aid of simple hygienical measures. But it sometimes hap- pens that in spite of every care, this complication, particularly when it has come on very rapidly, carries off patients by producing effects variable in their nature, and which it behooves us to understand. When anasarcous scarlatinous patients complain of sudden and violent headache, accompanied by disordered vision, convulsions are to be dreaded. It is necessary that you bear in mind this fact, both that you may inform the families of your patients of what may happen, and that you may use means to prevent the convulsions, which is sometimes possible. The meas- ures occasionally employed with success consist in keeping the head in an elevated position, placing the patient so that his legs hang over the bed, and purging him somewhat briskly. But in the majority of cases, do what you will, the convulsions supervene, and often prove at once fatal. In other cases, they recur at intervals of an hour and a half, of an hour, of half an hour, and then they become almost continuous, one fit beginning before the previous one is quite terminated, till at last the patient dies in a state of coma. It sometimes happens that the anasarca gets possession of deepseated parts. I have seen it seize the veil of the palate, the uvula, the epiglottis, and the aryteno-epiglottidean ligaments. In the child in whom we wit- nessed these lesions, symptoms of oedema of the glottis immediately set in ; and it was only by an energetic cauterization of the upper part of the larynx that life was saved. My colleague, Professor Bichet, mentioned to me his having been called to a child affected w ith this description of consecutive oedema of the glottis, in whom he was obliged to have recourse to tracheot- omy to prevent impending death. For persons to be carried off in scarlati- nous anasarca by this affection of the respiratory passage is not uncommon: suffocation takes place all the more readily, that the throat having been previously in an inflamed condition, an extension takes place of the inflam- mation to the aryteno-epiglottidean ligaments, where it becomes the head- quarters of an oedematous turgescence; and also the more readily, that tumefaction of the pharynx complicates the swelling of the upper orifice of the larynx. I have now to speak of some other affections which occur in the wane of scarlatina, which, though they begin to be better known than formerly, are still much less familiar to practitioners than the complications I have already described. I allude to malignant pleurisy, pericarditis, and rheuma- tism. The latter I have already referred to. In treating of eruptive fevers, it is usual to say that there is a peculiar tendency to thoracic affections in measles: the statement is correct, for measles attack the bronchial tubes first, and in preference to all other parts: it there declares its presence before any- thing can be seen on the skin, just as scarlatina makes its existence known by the sore throat prior to the appearance of the. cutaneous eruption. The first symptom of morbillous fever is pulmonary catarrh, and hence it is easy to understand how this affection, when more than ordinarily severe, should pretty frequently give rise to inflammation of the lungs. Thus it happens that when the fever continues on the seventh or eighth day of an attack of measles, it is almost a certainty that the patient has either acute catarrh, pneumonia, or perhaps pleurisy. But authors are unanimous in stating that scarlatina has no tendency to attack the thoracic organs. In truth, these organs are not assailed during the acute period of the disease; but they enjoy no such immunity when it is on the wane. It is not un- common after scarlatina, both in those who are, and in those who are not affected with anasarca, to meet with the sudden occurrence of chest symp- 154 SCARLATINA. toms; but it is not, as in measles, the lungs which suffer, but the serous membranes-the pleurae and the pericardium. Pleurisy occurring as a complication of scarlatina is generally of a bad kind, not only in respect of the rapidity with which effusion takes place, but also in respect of the quality of the effused fluid. About the eighth or tenth day of the pleurisy, the effusion is often of a purulent character, as in puerperal pleurisy. This production of pus depends upon the fact, which we cannot explain, that there exists a condition of general contamination, in virtue of which scarlatinous inflammations have an extreme tendency to suppuration. At the Children's Hospital, I had occasion to perform para- centesis of the chest in a scarlatinous child who, so early as the twelfth day, had pus in the pleura. In another little patient, I performed the same operation at the twelfth day of the pleurisy, and withdrew seven hundred and fifty grammes of perfectly formed pus.* This child had become ana- sarcous without having had the eruption, but there could be no doubt as to the nature of the disease, as scarlatina was prevailing in the household. I shall have to say more regarding this case immediately. In scarlatinous pericarditis, the tendency to suppuration is not so strong as in scarlatinous pleurisy. Scarlatinous pericarditis is also less frequent, and comes on more gradually. The relation which exists between inflamma- tion of the pericardium and scarlatina was pointed out by Graves, and has been established in a very remarkable manner, especially by Dr. Thore, jun. He has shown that in a certain number of patients convalescent from scarla- tina, some died from acute hydro-pericarditis, and others recovered after having had the same affection.t Articular rheumatism, as I have already said, is an exceedingly common complication of scarlatina. We have seen it in the acute stage of the dis- ease, and have met with it in adults in a proportion of cases greater than that in which it is generally believed to occur. We have also encountered it during the wane of the disease. The same occurrence was pointed out by " In a great number of cases," he writes, " I have met with articular rheumatism as a sequel of scarlatina." Similar statements have been made by other reliable observers, among whom may be mentioned Drs. Pidoux, Murray, and Valleix. The coincidence of rheumatism with scarlatina was nevertheless a generally forgotten fact, and consequently for several years past I have been constantly insisting upon it in my lectures. It is a singular eccentricity of scarlatinous rheumatism that it rarely assumes a formidable character: it is more localized, but less liable to return than ordinary rheumatism ; when it has once left a joint, it seldom comes back to it: generally, it goes away quickly and spontaneously, with- out requiring any treatment. The manifestation of the rheumatic diathesis in scarlatina gives, however, up to a certain point, an explanation of the development of pleurisy and pericarditis: it assists us in understanding why these affections are as frequent as they are, and why it happens that endo- carditis occurs as you yourselves have seen and as authors have stated. Generally speaking, in the first instance, scarlatinous rheumatism attacks the joints, and then the serous membranes of the heart and the pleurae, but sometimes, like pure rheumatism, it seizes the thoracic organs at the first * Perfectly formed pus weighing 750 French grammes, may be estimated as measuring rather less than British imperial pints.-Further particulars of this case will be found at p. 157.-Translator. f Thore, fils: De 1'Hydropericardite Aigue Consecutive a la Scarlatine et de son Traitement. Archives Generates de Medecine, fev. 1856, 5me serie, T. xii, p. 174. J Graves: Lemons de Clinique MGdicale. SCARLATINA. 155 brunt, without touching the articulations. Sometimes also, it takes the terrible and pitilessly fatal suppurative form. In point of fact, it is as a sequel of scarlatina and puerperal fever that we see suppurative rheumatism. For the first few days, the affection appears to be mild, then the articula- tions become painful, intense fever sets in, delirium supervenes, ataxo-ady- namic phenomena appear, and death closes the scene. On dissection, pus is found in the articular cavities and in the sheaths of the tendons. Such are the complications of the wane of scarlatina which belong to the group we named immediate; the mediate complications come on at a much later period, and are linked with-are sequelae of-those of the first group. St. Vitus's dance is the most important of the mediate sequelae of scarla- tina. In children you will see this affection following very close upon the exanthematous fever, showing itself in three months, two months, or even in six weeks. The remarkable researches of Dr. Germain See have thrown light upon the relations which exist between rheumatism and chorea.* His researches and later observations, including my own, justify us in stating that it is unusual for children to escape St. Vitus's dance who have had attacks of acute articular rheumatism; and to this statement may be added, as a sort of corollary to it, though requiring to be received less absolutely, that a child who has had St. Vitus's dance generally has rheumatism sooner or later. In chorea, consecutive to scarlatina, the bellows-sound indicates the existence of cardiac lesions, the result of pre-existing endocarditis. And sometimes the rubbing pericardiac sound, the last characteristic manifesta- tion of scarlatinous rheumatism, points out to us that it is by the rheuma- tism that the convulsive neurosis is linked with the attack of scarlatina, and constitutes one of its mediate sequelae. You have often seen suppuration supervene in different parts of the body after exanthematous diseases: you have especially seen the boils,the super- ficial and deep abscesses which indefinitely prolong the convalescence of confluent small-pox, and endanger the life of the patient. You recollect a case which we recently lost, in St. Agnes's Ward, from exhaustion caused by these colliquative suppurations. After scarlatina some of the mucous membranes, particularly those of the nose and ear, remain for months or even for years affected with chronic eczema. Some of you may very recently, and not without surprise, have seen me make a retrospective diagnosis of scarlatina from having before me eczematous coryza. The patient to whom I refer was a woman who came into hospital for a condition of general discomfort, characterized by exces- sive debility and absence of fever. She was affected with eczematous nasal catarrh. I observed that she also had on the elbows excoriations covered with crusts of comparatively recent date. I attributed the excoriations to violent rubbing, the rubbing to delirium, and the delirium to a fever. I further concluded that the fever was probably scarlatina, as that fever frequently produces delirium, and brings coryza in its train. In reply to my interrogations, the woman said that a month previously she had had scarlatina, which had been accompanied by delirium, and followed by gen- eral debility. My diagnosis was not the result of inspiration, but was a logical deduction from an association of ideas, and a bringing together of phenomena. The lesion of the mucous membrane sometimes extends to the deeper parts, caries and necrosis of the bone taking place. Other conse- quences may also result, such as lachrymal fistula, perforation of the tym- panum, and loss of the small bones of the ear; caries of the petrous portion of the temporal bone, leading to incurable deafness; facial paralysis, and, * Germain S£e : Memoires de 1'Academie de Medecine. Paris, 1850, t. xv, p. 873. 156 SCARLATINA. unfortunately in not a few cases, to inflammation of the meninges, and abscesses of the brain at points contiguous to the affected bone. These ter- rible occurrences sometimes follow measles, but not so frequently as they succeed scarlatina. We have now come to that part of our subject which is the most difficult, and which is likewise, from a practical point of view, the most important. I refer to disguised scarlatina, to which I have given the name of defaced scarlatina [scarlatine frustef You know what an antiquary means by a defaced inscription; it is an inscription the greater part of which is obliter- ated, and of which there may remain only a line, a letter, or a point. Dis- eases, too, are defaced; or, in other words, they present nothing for the physician to read but a single word of the symptomatological phrase, and with this one word he has to reconstruct the entire phrase, just as the archaeologist or the numismatist has to restore the effaced inscription by filling up the blanks in the remaining letters. Deciphering is a department with which the physician and the antiquary have to become acquainted by the use of very similar means: the antiquary must begin by learning to read what is written on well-preserved medals and unmutilated stones; and at the beginning of his studies the student of medicine requires to recognize in a disease the aggregate of its characteristic symptoms; but, by and by, as the skilled antiquary deciphers a lost inscription by a remaining word or letter, so the student becomes a skilled physician, and will divine the whole nature of a disease from a single sign. Of all diseases, gentlemen, scarlatina is that which is most frequently defaced [fruste]. A case in point will be more useful than an elaborate description. In 1829 a friend wrote to inform me that scarlatina was prevalent in a little village near Mennecy, in the department of Seine-et-Oise, and that it was most severe in the communes of Villeroy Castle. I was particularly pleased to go to study this epidemic, as, in consequence of the castle being perfectly isolated from the village, I could easily follow all the movements of the disease. I saw members of the same family who, after having had sore throat without eruption, were afterwards proof against scarlatina, though surrounded by cases of various degrees of severity. Their sore throat had been of a very aggravated form, and accompanied by ardent fever: the red- ness of the pharynx was very characteristic, and the consecutive stripping of the tongue left no room for doubt as to the nature of the affection. I saw other patients who had the original disease apparently very slightly, as they had only drooped a little for eight or ten days, but who, nevertheless, after- wards became swollen, and passed blood with the urine. At that date we were not acquainted with albuminuria. I was struck by the facts I have now stated, and I came to the conclusion that the persons who had only had eruption and consecutive anasarca, those who had only had anasarca, and those who had only had sore throat, had all had scarlatina, the affections seen in all of them being manifestations of that disease. At Meaux, in 1854, along with my accomplished friend Dr. Blache, I observed similar occurrences. A young girl, fourteen years of age, took violent scarlatina, characterized by atheromatous sore throat, intense fever, and the specific eruption. Some days later her sister, living in the same house, was seized with similar symptoms: almost at the same time a lady's maid sickened: two or three days afterwards a valet, who had remained the whole day in the apartment with the invalids, became affected with violent sore throat, accompanied by a deposit of pulpy matter on the tonsils, a red, and subsequently peeled tongue, burning fever, but no eruption. It was evident to me that the family physician, Dr. Saint-Amand, was right in believing that all had had scarlatina: that the valet, being in the midst SCARLATINA. 157 of the epidemic influence, had taken the fever like the other members of the family, but in a different form: in him the inscription "scarlatina" was defaced, whereas, in the other cases, it was complete. Another member of this household, a boy of six years of age, all at once, and without having had a moment's previous illness, became swollen. Dr. Blache and I were then called in in consultation. We considered the case to be one of scar- latinous anasarca coming on at the first brunt of the attack of scarlatina. The anasarca was considerable, and accompanied by hsematuria. The father and mother, persons very watchful over the health of their son, assured us that on the morning of the very day on which the boy became ill, he had taken his breakfast as usual: and the master of the boarding-school where he attended stated that he had played in his customary manner. In this case, then, there was neither fever nor eruption, and scarlatina was detected solely by the individual symptom for which we were called in. Eight days later the boy had a double pleurisy: death was supposed to be impending, when Dr. Blache and I were again called in. We detected effusion in both pleurae: four days later we found that one side of the chest was restored to its natural state, and that the other was enormously distended. We proposed, and forthwith performed, paracentesis, withdrawing 750 grammes of pus. For two or three months Dr. Saint-Amand injected iodinous solutions into the pleurae. Although the lung was perforated during the treatment, the child recovered, and at present enjoys most excellent health. I have not met with another similar case. But as regards examples of defaced scarlatina, you will find them scattered in the works of authors. Graves has in par- ticular mentioned several, some of which I will now quote from his clinical lectures. " F was taken home from a school where scarlatina was prevailing: he complained of pain in the throat on swallowing, slight headache, and nausea. Next day the tonsils were swollen, and there was increased difficulty in swallowing: the pulse was sharp, and the skin was hot, but there was no trace of eruption. These symptoms, without increasing in severity, con- tinued for three days, and then disappeared. Before this boy had com- pletely recovered, his father and two sisters took scarlatina. In the two sisters the eruption appeared, and terminated in desquamation. In the father there'were only a few small red points on the skin, and no subsequent desquamation occurred. " O likewise came home from school with scarlatina. During his attack his two sisters and brother took the disease. In the three it showed itself in the form of an eruption of small spots on the skin. At the same time, and in the satne house, a valet and a lady's maid were seized with very violent sore throat and high fever, which continued for some days: in neither case was there any eruption." These cases of Dr. Graves are identical with others which I have met with. In the following very curious narrative relating to a physician's family, we see scarlatina showing itself only by anasarca at the onset of the illness, just as occurred in the lad whose case I described to you a few minutes ago. The facts were communicated to Dr. Graves by an eminent practitioner of Dublin. Some years ago, scarlatina broke out in this practitioner's family. It attacked all his children with the exception of one young lady, who had no symptoms whatever of the disease, although she waited on her sisters during their illnesses. All was going on well, and the family was sent to the country for change of air: the sister who had not been ill went with the others. In the country, to the great surprise of all, this young lady was suddenly seized with that special form of anasarca observed in those 158 SCARLATINA. who have had scarlatina. Her father, who attended her during her illness, was exceedingly struck with the occurrence: he observed the case with very special attention, and came to the conclusion that it was one of latent scarlatina. Dr. Graves, in speaking of these cases, remarks that they are very inter- esting in a pathological point of view, as tending to prove that diseases originating in contagion very often do not exhibit their ordinary series of characteristic symptoms. The quotations now made from the Irish author show that similar phe- nomena occur under the Dublin and under the Parisian sky. You will assuredly meet with these cases of defaced scarlatina ; and you will do well to accustom yourselves to recognize them. Graves maintains that they can only be cases of scarlatina, because the disease being essentially contagious, it is impossible for the persons who have only had sore throat or anasarca to be in the midst of their scarlatina-stricken families, and yet be the only ones who have been exempt from attack. In December, 1860, I saw with my friend Dr. Leon Gros, a young man of fifteen whose case furnishes us with a new example of defaced scarlatina -a case in which the diagnosis would have been impossible without assist- ance from accessory circumstances. This youth came home from college with a little fever and an insignificant sore throat. The illness was so slight that Dr. Gros did nothing; and after two days of trifling indisposition the patient was quite well. A few days afterwards, his younger sister took scarlatina; and during her convalescence, the brother was seized with hiematuria which continued more than a month. I never entertained the least doubt that this young man had communicated scarlatina to his sister, and that his htematuria was the sequel of his slight febrile attack. Dr. Gros did not feel quite sure as to the accuracy of this view. The young man did not contract scarlatina after his sister, and must have had it before her, if he can be said to have had it at all. In this case, albuminuria continued for nearly a year; and it required the most assiduous and skil- ful treatment on the part of Dr. Gros to prevent the patient becoming a victim to an exanthematous fever which had begun so mildly as to make its very existence a matter of doubt. Eruptive diseases have a fatal tendency in this sense, that they have determinate characteristics against which we cannot prevail. This remark is equally applicable to diseases in which the eruption shows itself on the skin, and to those in which it conies out on the mucous surface of the intes- tine, as in dothienteritis or putrid fever, which is an eruptive affection of the alimentary canal. In treating these diseases, the physician must not lose sight of the great practical fact that it is imposible to stop the prog- ress of a putrid fever, and equally impossible to cut short an attack of small-pox or measles. It is possible by injudicious treatment, at great peril to the patient, to retard, and in some degree to modify the appearance of the eruption, but the evolution of an exanthematous fever cannot be prevented. Treatment ought therefore to be restricted to the alleviation of the symptoms and complications which arise during its course. The physician ought in this class of disease more than in any other, to be the servant and interpreter of nature-minister natures et interpres-for, to con- tinue the quotation,-quidquid meditetur etfaciat, si natures non optemperat, natures non imperat: he ought to remain passive when things take their regular course. If no untoward symptoms occur, there is nothing for him to do but to fold his arms, for at the end of a few days the malady will have safely run through all its stages. Even when eruptive fevers assume SCARLATINA. 159 some threatening symptoms, our interference, it must be confessed, proves of very little use. The auspicious circumstances in which the interference of art proves beneficial occur more frequently in scarlatina, than in mea- sles, small-pox, or putrid fever. 1 now propose to point out to you the good which the physician can do in scarlatina. It is of the utmost importance that he have always pres- ent in his mind the fact, that this disease differs much from itself both in symptoms and severity: he must always remember that it is sometimes exceedingly mild, and at other times as terribly malignant as typhus or plague: in a word, he must bear in mind the type of the prevailing epi- demic. It behooves him not to set down to the account of successful treat- ment results entirely attributable to the mild character of the epidemic, and equally to avoid throwing the blame of unfortunate issues upon the treatment, when they are really dependent upon the inherent malignity of the cases. Epidemics of scarlatina may be of a formidable type in respect of an entire population, or in respect of a single family. The malignity may, so to speak, remain confined to one small circumscribed centre, within which nearly all who are attacked will have the disease in a malignant form. As a case in point, I may refer to a melancholy statement lately made public in an English newspaper, to the effect that a clergyman of the city of York lost, by scarlatina, in one week, his six or seven children. It seems as if the scarlatinous poison with which such unfortunates are infected has a special energy, and that the constitutions of every one of them is specially disposed to receive it. Whether the malignity is depend- ent upon the nature of the disease itself, upon the constitution of the epi- demic, as Sydenham and others allege, or whether upon the idiosyncrasies of individuals, as Stoll believes, there is no uncertainty as to the great fact, that when scarlatina breaks out with fury in a family, killing the first per- son attacked, there is cause to fear that it will carry off other victims; and that, on the other hand, when its first assault upon a family is moderate, when the first cases are mild, there is reason to hope that all the subsequent cases will likewise be mild. It was necessary to say what I have now said before entering upon the subject of treatment, so that you might be put on your guard against yourselves. I cannot too often repeat that the best treatment will fail when the type of the disease is essentially bad, and that when it is mild, recovery will be the rule, even when inappropriate or injurious measures have been employed. There is a general agreement among all epidemiologists that injury is done by pursuing such antiphlogistic measures as local or general bleeding, too active purging, and very low diet. Most authors who have seen, studied, and recorded several successive epidemics point out the danger of this kind of treatment in severe cases of scarlatina, even when acute inflam- matory affections have supervened, such as phlegmon of the tonsils, lymph- atic glands, or cellular tissue. Bleedings and the application of leeches generally produce a bad effect, probably because they are employed to com- bat the symptoms of a septic disease, a malady of a bad character-mail moris-for antiphlogistic measures almost always prove disastrous in malig- nant diseases. Epidemiologists, however, while they condemn antiphlogistic treatment on account of the evil which they have seen it produce, inculcate that although energetic purgatives are injurious, mild purgatives, such as mer- curials and the neutral salts, are of real service, when given in moderate doses. My own experience has demonstrated to me the truth of that doc- trine. If the alimentary canal is loaded, and signs of faulty chylification 160 SCARLATINA. exist, it is advantageous to open the bowels by administering a purgative suited to the age and strength of the patient. I cannot participate in Sydenham's dread of diarrhcea, so long as it remains moderate and is depend- ent upon a loaded condition of the alimentary passage. I have already said that in scarlatina, particularly in the acute stage, patients are frequently carried off by nervous affections. These affections may have their starting-point in the centres of organic life, in which case they are characterized by an extraordinary elevation in the temperature of the body, by vomiting and intractable diarrhoea ; or they may originate in the centres of animal life, when the phenomena are delirium, coma vigil, jerking of the tendons, and convulsions. I have already insisted on the fact that vomiting and intractable diarrhoea at the onset of scarlatina are very unfavorable symptoms, and that it is difficult to control them by medicines. It is in vain that we administer opiates and poisonous solinace- ous drugs. The vomiting and diarrhoea are sometimes moderated by the use of tepid baths, and by administering ice, effervescing draughts, and small doses of calomel. They are generally aggravated by bloodletting. Cold affusions have been proved by experience to produce beneficial effects in these affections dependent on disturbance of the nervous system, particularly on those originating in the centres of animal life; but never- theless, it is with trembling that the practitioner employs them. Currie was the first to formulate rules for their use. He employed cold affusions with a certain measure of success in a large number of very bad cases of scarlatina. Emboldened by fortunate results, he became still more urgent in his recommendation of this method of treatment, and laid it down as a general rule of practice that it ought to be adopted in scarlatina when there were formidable nervous symptoms, such as delirium, convulsions, diarrhoea, excessive vomiting, and great heat of skin. The patient being placed, naked, in an empty bath, has thrown over his body three or four pails of water at a temperature of form 20 to 25 degrees of the Centigrade thermometer. The continuance of the affusion is from a quarter of a minute to one minute, which latter is the maximum duration. The patient is immediately afterwards put back to bed, without being dried, but being wrapped up in blankets and properly covered. Reaction is gen- erally established within fifteen or twenty minutes. The affusion is repeated once or twice in twenty-four hours, according to the severity of the symp- toms. This treatment ought at once to be resorted to, when the nervous phenomena assume such intensity as to threaten imminent danger, and they ought to be repeated at proper intervals till the symptoms have so far abated as to relieve the physician from serious anxiety. This practice must be carried out in watchfulness. It is above every- thing essentia] not to require the support of public opinion to justify your instituting a method of treatment which has the appearance of being so audacious. You must be actuated by a profound sense of duty to venture to oppose the popular prejudice-a most disastrous prejudice-which insists upon patients with eruptive fevers being kept on hot drinks, and wrapt up in a more abundant supply of blankets than they were accustomed to when in health. I say that there is no popular prejudice more disastrous, for there is none which so often occasions the death of patients. Nevertheless, the mighty voice of Sydenham, who though dead two hundred years still speaks, and the authority of the most mature modern physicians, ceaselessly oppose it without avail. Hence the difficulties which the young physician has to encounter, when he feels that it is his duty to have recourse to cold affusions in scarlatina. These difficulties are all the greater, that it is in cases which threaten to prove fatal that the treatment is indicated. When SCARLATINA. 161 you adopt it, you know that the disease only presents you with one chance of recovery against two of death : and you can foretell the reflections of the family in the event of your efforts not being crowned with success! I have long been in the habit of employing cold affusions. I used them, however, in my private before administering them in my public practice, because I never venture for the first time upon a new mode of practice upon my hospital patients. I declare to you that I have never resorted to the employment of cold affusions without obtaining beneficial results. I am far from pretending that all my patients so treated have recovered: like my colleagues, I have lost the greater number, but even those who died experienced a temporary relief from suffering, and the affusion, so far from proving injurious to them, always moderated the symptoms, and also seemed always to retard the fatal termination. The adoption of this practice sub- jected my popularity as a practitioner to great risks, and my resorting to it, from a profound conviction that it was right, has often been badly recom- pensed. But still, I have always firmly continued in the line traced out for me by duty, and now I do not hold to it with less determination, that I am less afraid than formerly of incurring responsibility. I perfectly appre- ciate your alarms: not because I suppose you doubt the goodness of a mode of treatment which perhaps you would not dare to resort to, but because I imagine that whilst consulting, in the first instance, the interests of your clients, you will naturally desire to protect your professional reputation, so liable to be blasted at the beginning of your career. However, remember that when the voice of duty commands, when your conscience tells you that the cold affusion ought to be administered, you must not flinch from having recourse to this method of treatment because it is opposed to the prejudices of the public. But in place of fighting face to face with prejudice, in place of taking the bull by the horns-pardon me the phrase-evade the diffi- culty, by adopting such manipulations as will lead the patient, and still more those in attendance, to believe that the affusions are warm and not cold. I have already repeatedly said that scarlatina, especially when its form is malignant, is of all diseases that in which the temperature of the body rises to the highest point. Very often it rises to forty-one degrees, which is three degrees above the normal standard. Very well, then: in place of giving your patients cold affusions, give them mere lotions of water at twenty-five degrees-that is, of water fifteen degrees under the temperature of the skin in scarlatina, and therefore, relatively to it, cold. Let the pa- tient be placed on a folding-bed : and then, let the entire body, first the anterior and then the posterior surface, be rapidly wetted with sponges soaked in this water at twenty-five degrees; and when this has been done, let him be rolled up in blankets and put back into his own bed, follow- ing the same rules as after the cold affusion. Though these tepid lotions are less efficacious than the cold affusions, they are productive of real bene- fit. Consequent upon their employment, the following effects are observed. The skin previously characterized by extreme aridity and stinging heat, in half an hour becomes cooler and moist. The diminution in the rapidity of the pulse is a still more remarkable phenomenon: from between 160 and 180 in children, it falls to 140 or 130; and from 140 or 150 in adults, to 120 or 115: there being consequently a fall ranging between 30 and 40 beats. Simultaneously with these amelioriations, the severity of the cere- bral symptoms diminishes, and there is a proportionate decrease in the pro- fuse diarrhoea ami excessive vomiting, symptoms dependent upon disturb- ance of the ganglionic nervous system. You thus obtain-for a very limited time I admit-a remarkable sedative effect from the tepid bathing. The VOL. I.-11 162 SCARLATINA. benefits, I say, are not long continued, for sometimes in two or three hours the symptoms have returned. It is necessary, in point of fact, to renew the lotions or the cold affusions two, three, or four times in the twenty-four hours, and sometimes to continue to employ them for five or six consecutive days. I saw, very lately, along with my excellent friend Dr. Baret, a lad of thir- teen suffering from very severe scarlatina. From the third day of the attack, the nervous symptoms assumed so formidable a character that Dr. Baret contemplated the employment of cold lotions: I also believed them to be indispensable. The relations were terrified, but with that resignation so becoming in intelligent persons who feel their absolute incompetence to judge medical questions, they allowed the proposal to be carried out. Each bathing was followed by considerable amendment; and at the end of four days, when the lad was out of danger, they loudly proclaimed that he owed his life to the cold applications. Relatives are much reconciled to the use of the cold affusions and cold lotions by the circumstance, that the skin, pale before, almost always be- comes much redder after they have been employed-there is more eruption seen. This method of treatment, so far from effacing the eruption, increases it. This is so palpable that it is noticed by the relativeslof the patient, who will, so long as danger lasts, often be the first to solicit the renewed appli- cation of cold water, so evident to them is the amendment which has resulted from the treatment, and so struck are they by the material fact of a brighter red having been imparted to the eruption. It is nevertheless true, that if the amendment noticed is not perfected by recovery, if death come, in the inevitable march of events, they too often forget the encourage- ment they gave to your proceedings. Some of you, gentlemen, recollect a case which I am now going to relate in detail. On the 10th of May, 1857, a stout, fine girl of twenty came into Professor Rostan's wards with scarlatina, in an exceedingly severe form: she had been ill for two days. My honorable colleague had the goodness'to show me this patient, and to propose that she should be received into my wards. She had violent delirium and excessive restlessness: her pulse was 144 in the minute ; there was great heat of skin, and scarlatinous sore throat of aggravated character. The restlessness and delirium were serious and threatening symptoms. Professor Rostan wished to have my opinion as to the treatment to be adopted: he inclined towards bloodletting; and I proposed cold affusions. The patient was received into my wards. On her admission, I had her put into an empty bath; to accomplish this, it was necessary to have the assistance of four persons, so great was her violence. I then, somewhat slowly, poured over her body two ewers, each containing about two litres of water, at a temperature of about 15° Centi- grade [59° F.]. I at the same time watered the face and limbs: after this treatment, without being dried, she was wrapped up in a blanket and put back in her bed. Her violence was by this time sensibly calmed, the pulse had fallen ten beats, and there was less of a burning character in the heat of skin. I advised my chef de clinique, Dr. Blondeau, to see her again towards evening, and repeat the affusion, if, as I hoped, the first application had produced a change for the better. In the evening, the affusion was repeated as in the morning, the patient offering less resistance. Soon after the evening affusion, the heat of skin subsided greatly; and the pulse fell to 120 ; in the morning, as already stated, the pulse was 144. The delirium ceased; she passed a quiet night; and at the visit next morning answered my questions intelligently. The disease had resumed its normal course, disentangled from all complications. Although this patient had slight SCARLATINA. 163 albuminuria for eight days, she left the hospital quite recovered from her attack, and in perfect health, at the beginning of July. Desquamation was not completed till near the end of June, forty-five days after the onset of the attack of scarlatina. There are two cardinal points in this case, gentlemen, to which I wish to call your attention: the first embraces the diminution of the febrile heat, the lessening of the rapidity of pulse, the cessation of delirium and restless- ness; and the second is the increase of the eruption. The cold affusion, so far from driving in the eruption, brings it out more vividly. The young woman whose case I have just detailed was at the end of the third day of the attack when X saw her, and the eruption, therefore, was at its maximum of intensity : nevertheless, it became more vivid after the application of the cold water. With respect to the diminution in the frequency of the pulse, the lowering of the temperature, and the cessation of delirium-ataxic symptoms which as a rule increase in severity up to the sixth or seventh day of the disease-they did not merely remain stationary, which would have been a relative benefit, but they became more moderate, and ultimately ceased. A few days later, on the 23d May, 1857, another opportunity was afforded in my wards for employing the same treatment; but the case was of so com- plicated a nature that we could not hope for similar success. The patient was a woman of 24 years of age, who ten days previously had given birth to a healthy infant, and four days after her confinement was attacked by scarlatina. There were no symptoms specially dependent on recent delivery -no signs of peritonitis or phlebitis-but the patient was not the less in a puerperal condition when the exanthematous fever declared itself with great violence. When admitted into our wards, she was suffering from great excitement and delirium. The skin was very hot, and covered with a vivid red eruption ; the tongue was dry and black ; there was considerable oppression at the chest, and the pulse was 136. Without being deterred by her puerperal state, and the lochial discharge which was flowing in a nor- mal manner, my chef de clinique, Dr. Blondeau, who saw her in the evening, had her subjected to the cold affusion: I approved of the treatment, which 1 would myself have ordered. Immediately after the affusion-during which she had a faintingfit-this unfortunate woman felt much better: the delirium subsided as if by enchantment; there was relief from the violent pains, chiefly in the loins, of which she had been complaining; and she expressed herself as grateful for this rapid relief. A few hours later, how- ever, there was a return of the nervous symptoms. She passed a very bad night, and at my visit next morning, the delirium, excitement, and oppres- sion at the chest were extreme. The pulse, which had in the evening, after the affusion, fallen from 136 to 120, had returned to its former frequency. The eruption continued at least as vivid as before the employment of the cold affusion. I administered a second affusion: the delirium ceased at once, and the excitement became less. The patient again experienced a feeling of improvement, similar to that which she had felt after the treat- ment on the previous evening, and the recollection of that feeling always present to her mind, caused her during her lucid moments to ask for the cold water. Those of you, gentlemen, who were present at the visit can testify to the beneficial effects which resulted from the treatment; the pulse again fell from 136 to 122, but the great oppression at the chest continued, and could not be in any way explained by the state of the thoracic organs, auscultation presenting nothing particular. This symptom gave us serious anxiety as to the issue of the disease which was in so formidable a manner complicating the puerperal condition. I seize this opportunity of telling 164 SCARLATINA. you how very perilous scarlatina is when associated with the puerperal state: the patients either succumb under aggravated nervous symptoms which leave no lesions appreciable on dissection, or from inflammations of the serous membranes-the pleurae, pericardium, or peritoneum-passing rapidly into suppuration. In 1828, Drs. Ramon, Leblanc, and I were sent by M. de Martignac, then Minister of the Interior, to study the epidemics and epizootiae preva- lent in old Sologne, that part of France which lies between the rivers Cher and Loire, extending from Blois to Gien. We saw occurring simultane- ously with severe cases of scarlatina, numerous eases of membranous sore throat. Scarlatina was particularly severe at Cour-Cheverny, a commune situated four miles south of Blois: and it had proved so specially fatal to puerperal women, that even the very poorest were leaving the place and going to Blois to be confined. The district physician informed us that he had lost nine cases. Now, as you know, puerperal epidemics are very rare in country places. Generally speaking, pregnant women are proof against epidemic influences, but in thirty-six cases, forty-eight hours after delivery, the scarlatinous eruption showed itself, and in a few days the patients were dead. The puerperal state, therefore, is a very serious complication of scarla- tina. This was seen in our patient in number 19. The disease called puerperal fever was prevailing in Paris. The Maternity Hospital had in consequence been recently closed, and I had cases of this formidable malady in my wards in the Hotel-Dieu. New-born infants were carried off by erysipelas of bad type, a manifestation of puerperal fever in young subjects, and which proves fatal to them without leaving any appreciable lesions in internal organs: Our patient you see was in the most unfavorable circum- stances. Oppression at the chest, when unconnected with any material affection of the respiratory passages, is an exceedingly serious symptom in a great number of septic diseases, particularly in puerperal fever, typhoid fever, and cholera, indicating a profound disturbance of innervation. This kind of dyspnoea, unconnected with any appreciable lesion of the lungs, pleurae, heart, pericardium, or great vessels, is one of the most unfavorable symptoms which can occur. The symptoms referable to the nervous system became more formidable, and our patient died during the day. On opening the body, our attention was chiefly directed to the lungs, heart, and membranous coverings of the encephalon. I was the more desirous to discover whether there was any lesion in these latter organs, as in the girl who was the subject of our first case, the nervous symptoms were referred to the meninges. The autopsy, which was carefully made, revealed nothing. The encephalon, attentively examined, presented no trace of lesion; and in the lungs, there was nothing found except slight congestion, such as we find in persons who have died a violent death. The heart, peri- cardium, and large vessels were in a perfectly healthy state. The results of the microscopic examination did not surprise me, for I had often ex- amined the bodies of persons carried off under similar circumstances, and had never met with any appreciable alterations in the encephalon, which, however, is not equivalent to saying that it is never the seat of any organic changes. These morbid changes are met with in connection with certain symptoms referable to the nervous system, but essentially different from the symptoms presented by the patient whose organs are now under our consideration, and which organs had no trace in them of the symptoms which had occurred during life. We, therefore, had to do in this case with the delirium to which our predecessors gave the name of delirium sine materia-cerebral disturbance SCARLATINA. 165 without appreciable lesion of the brain. We all fortn a strange conception of the nature of delirium. When it occurs in the course of an acute affec- tion, we at once explain it by invoking cerebral hyperaemia, and our theory, which has in it something of the leaven of the old physiology, is based on a belief in the irritation of the organ of the function which is disordered. Such was the.language used in 1820, 1824, and 1825; and at the present day, these ideas exist in a modified form. There is, it appears, therefore, a desire to attribute functional disturbance to a state of congestion leading to inflammation. The simplicity of the theory certainly makes it attrac- tive. A man is delirious, he coughs, he vomits bile: nothing is easier than to say that he has cerebral, pulmonary, or hepatic hyperaemia. But at the autopsy, the aspect of the case is changed, when the examination of organs frequently demonstrates that an erroneous opinion has been formed. The supposed hyperaemia does not in any way reveal its past existence: reason- ing, moreover, shows a connection between the phenomena during life and appearances after death appreciable to the senses. Is not anaemia-the condition exactly the opposite of hyperaemia-accom- panied by similar symptoms ? Do not the animals whose throats are cut in the slaughter-houses die in convulsions from loss of blood? What are these convulsions, if they be not a sort of delirious action of the muscles ? Why may not anaemia produce in the same way a delirious action of the intellect? A woman, in consequence of profuse metrorrhagia, is attacked with great functional disturbance of the cerebro-spinal centres: in such a case, it is clear that hyperaemia cannot be assigned as the cause of the nervous symptoms. In such cases, we have an absolute demonstration of the fact, that anaemia can produce convulsions, coma, and delirium. We have, therefore, no right to assert, as one is too often tempted to do, that these symptoms depend on congestion of the nervous system. There is no doubt evidence to show that they sometimes depend on that state, and on meningitis; but meningitis is far from being a condition essential to their production. In septic diseases, the conditions are very different, for then we have to do with real cases of poisoning. Whether the blood undergoes a great change under the influence of the toxic principle, or whether it is only the medium by which the poison is carried to the centres of nervous power, there to originate disordered action, still, the same thing which happens in septic diseases also occurs when we administer drugs having an action on the nervous system, such as belladonna, henbane, mandrake, thorn-apple, and hemlock, substances which cause delirium varying in character according to the individual substance given. The delirium caused by opium is different from that caused by members of the family Solinacese, and they again do not produce the same kind of delirium as is determined by the Um belli ferae. The differences in the character of the nervous symptoms resulting from the administration of different drugs are so distinctive, that a physician acquainted with their respective modes of action will, from the form in which the convulsions or delirium show themselves, be able to recognize the particular substance which has produced them. The septic poisons of scarlatina, measles, small-pox, malignant pustule, dothienteritis, or puer- peral fever, have also their special action on the nervous system. Why, therefore, should we be surprised to see these poison-diseases accompanied by delirium ? To explain this, is it necessary to have recourse to hyper- aemia, seeing that it is not taken into account in considering cases of poison- ing with vegetable substances? In both classes of cases, the symptoms arise independently of hyperaemia; and our inability to discover their cause is no reason why we should be forced to admit the existence of an unknown 166 SCARLATINA. action which we cannot explain. Moreover, delirium and other nervous symptoms may occur irrespective altogether of any toxic or septic cause: they may be produced by mere tickling, using the word [vellication] in the acceptation of the Latin verb vellicare. Cases are mentioned in which persons have caused women to die by tickling the soles of their feet. The unfortunate victims became exhausted and fell into a state of violent delirium, accompanied by extraordinary nervous phenomena. Tickling may by itself, then, produce delirium, or an exaggerated state of innervation caused by forced excitement of the nervous system, similar, for example, to a condition almost physiological, that which exists in the act of copulation. This tickling [vellication]-to continue the use of the word-this unnatural excitement of the sensibility, due perhaps to reflex action, is equally liable to occur in the nervous ap- paratus of organic life, and in that which regulates relative life. It is thus that we can explain certain formidable symptoms in children, such as delirium, convulsions, paralysis, and loss of vision, caused by the presence of intestinal worms, even when the worms occasion no decided pain in the abdominal viscera. In these cases,cerebral hypenemia plays no part; and even in other cases where the brain is directly implicated, congestion has no share in the production of the nervous phenomena to which I am now calling your attention. In the insane, in individuals who during many years have had frequent attacks of delirium, we occasionally find on dissec- tion lesions indicative of chronic inflammation having existed, but most frequently we meet with no traces of hypersemia. Still less will hypenemia explain that sort of delirium, or transient disturbance of the intellectual powers, to which men of the greatest abilities and best regulated minds are sometimes subject. Let us now return to the treatment of scarlatina by cold affusions. You must quite understand that I do not employ them indiscriminately in all ordinary cases of the disease, as is the practice of the extreme partisans of the treatment: I only use them to subdue serious nervous complications- formidable ataxic symptoms. We may also beneficially combat ataxic symptoms by internal remedies. In their first rank stand ammonia, and its preparations carbonate of ammonia and spirit of Mindererus, the latter being a mixture of acetate of ammonia with some empyreumatic products. Both preparations in doses of from two to four grammes, and the solution of ammonia in doses of from ten to twenty drops, may prove very useful. I may say the same of musk, which is prescribed in doses of twenty, thirty and forty centigrammes, and of which as much as a gramme may be given in twenty-four hours. Some prudence is required in the management of these remedies : they constitute an accessory means of treatment in the cases in which we use the cold affusions ; and when for any reason the affusions are not employed, ammonia and musk are our principal therapeutic agents. Scarlatinous sore throat accompanied by fibrinous exudation does not involve absolute danger, unless the exudation is excessive. Under obser- vation of the followers of any clinical practice, I have allowed patients laboring under this affection to remain without treatment; and this absti- nence from interference was very conspicuous in the case of a lad who occupied bed No. 17 in St. Agnes's Ward. In his case, the fibrinous exuda- tions and the pappy patches on the tonsils disappeared spontaneously within four or five days. Though this kind of sore throat undergoes spontaneous cure in simple scarlatina, the throat affection is generally intractable in the malignant form of the disease. I have tried cauterization with nitrate of silver and SCARLATINA. 167 with hydrochloric acid ; I have tried borax washes; I have prescribed chlorate of potash in gargles and potions; and I declare that they have all frequently failed to produce any beneficial results in the sore throat of malignant scarlatina. The least untrustworthy of these therapeutic agents is hydrochloric acid, which when applied twice a day has appeared to have some efficacy. This caustic requires to be employed with prudence and precaution. In children struggling to resist the application, there is a risk of burning the tongue, injuring the teeth, and touching the internal surface of the mouth, thereby almost always aggravating the evil without properly effecting the cauterization. But by holding the child in a convenient position, and separating the jaws by means of a tongue-depressor, it is pos- sible exactly to touch the affected parts with a hair-pencil soaked in the acid. Good results are sometimes obtained -by cauterizations effected in this manner twice in twenty-four hours for five or six days. Insufflation of alum and tannin, practiced alternately, are also very useful. When this bad form of the affection of the throat is met with after the acute stage of the attack, coming on suddenly about the ninth or tenth day with copious discharge from the nose, deafness and acute pain in the ears, horrible fetor of the breath, great frequency of the pulse, and depression of the vital power, I look upon it as a diphtheritic complication of the erup- tive fever. I have found that all means directed against it prove ineffectual. Styptic nasal injections of solutions of sulphate of copper, sulphate of zinc, nitrate of silver, of decoction of rhatany, and of tannin, as well as energetic cauterizations of the throat, have all failed: whatever was done, the pa- tients almost invariably died. In these cases, the general treatment is the most important: we must chiefly rely on diffusible stimulants, sulphate of quinine,*infusion of coffee, and especially on a system of tonic alimentation: but it too often happens that these measures prove of no avail. We must now consider the treatment of scarlatinous anasarca and its complications. As I have already remarked, anasarca occurs perhaps less frequently after severe cases than during, or at the decline of, mild attacks. It is sometimes a very formidable, and at other times, not at all a serious complication. When the anasarca is slight, hygienical measures, rest in bed, tepid drinks, and moderate diet are all that is required; and even in slight anasarca associated with some heematuria, the symptoms may be easily subdued by acid drinks, lemonade, decoction of uva ursi sweetened with spirit of turpentine, small doses of foxglove, and mild laxatives. But when the anasarca increases very rapidly, it is necessary to have recourse to other means for the prevention of the troublesome symptoms which then threaten. As the treatment required in the two forms of the affection is different, you require to keep both present to the mind. When the anasarca is accompanied by a real febrile reaction characterized by heat of skin, quickness of pulse, oppressed breathing, thirst and dry tongue, antiphlogis- tic treatment is necessary, and you may with great benefit bleed from the arm once or even twice : the relief afforded by the bloodletting is shown by a diminution of the phenomena of reaction. By following up the abstrac- tion of blood by the administration of calomel in minute doses-a specially excellent antiphlogistic measure-you deprive the anasarca of its acute character, while at the same time, by the purgative action of the medicine, you lessen the oedema. This result may now be accelerated by giving di- uretics, although before the institution of the antiphlogistric treatment they had been of no use. Should the oedema be of a cold character, unaccompanied by fever, you must abstain from bloodletting, and promptly administer those purgatives 168 SCARLATINA. which cause the intestinal mucous membrane to pour forth serosity in such abundance as to bring about the cessation of the anasarca, and you will also, with the same object, stimulate the urinary secretion by diuretics. If the relaxation, the loss of tone in the tissues, should be very great, it will be advantageous to combine the employment of tonics, particularly quinine, with the treatment nowT recommended, or to give large doses of the iodide of potassium, a remedy much lauded in such cases by Graves. The acute form of anasarca is often preceded or accompanied by hsema- turia, or at least by the passing of some of the constituents of the blood with the urine. All pathologists are agreed in attributing this passing of blood or of its elements to hypersemia of the kidneys, often inflammatory in char- acter, as is evident from its attendant febrile reaction. Measures of general depletion, such as I have recommended in the acute form of the anasarca, have a very beneficial influence on this kind of renal congestion. I concur with the unanimous opinion of clinical teachers that diuretics do harm by increasing the renal hypersemia, and consequently augmenting the quantity of blood passed with the urine. Benefit is often derived from the use of haemostatics, such as sulphuric acid or alcoholized sulphuric acid [eau de Rabel~]-the latter in doses of two, three, or four grammes a day, in a tisane sweetened with syrup of rhatany. Among the complications of scarlatina, anasarca is that which is most frequently brought on by exposure to cold. It is necessary, therefore, to protect patients as much as possible from this influence, particularly at the epochs of the disease at which, according to statistical data, the swelling is most liable to occur; that is to say, during the second and third week, and, in a very special manner, immediately before the fourteenth and twenty-first day. The precautions to be taken will be more or less rigor- ous according to the season of the year. There is no similarity, but on the contrary curious differences between small-pox, measles, and scarlatina, in their relation to the injurious influ- ence of cold. Sydenham thought that small-pox patients ought to get up every day, even when the eruption was at its height: and nothing hap- pened to show that patients treated in this way were disposed at any period of the malady to contract intercurrent affections through chills. Patients suffering from measles are neither so little affected by exposure to cold as variolous patients, nor so susceptible to it as scarlatinous patients. Upon some persons suffering from measles, cold seems to produce no impression, whilst it increases in others the bronchitis, the inseparable companion of the eruption : this affection may extend to the minutest bronchial ramifi- cations, and to the pulmonary tissue, giving rise to capillary bronchitis or a special form of pneumonia, the two most serious complications of measles. The pulmonary complication sometimes supervenes during a slight attack of anasarca. The susceptibility to cold is at its maximum in scarlatinous patients. Hence it is necessary to take the greatest possible precautions to protect the patients from exposure to chills. But in saying this, I do not mean to imply, that it is ever right, at any stage of the disease, to shut up the patient in a suffocating atmosphere, to load him with blankets, and excite him with hot drinks. A moderate temperature, no more blankets than he is accustomed to in health, and the use of tepid beverages, acidu- lated and slightly cooling, are the most appropriate measures. It is neces- sary, however, to confine scarlatinous convalescents to their rooms for a long time, to save them from the risk of exposure to sudden transitions of temperature, currents of cold air, and damp; for from such causes arise anasarca, hamiaturia, effusion into the pleurae and pericardium, or still worse into the ventricles of the brain. SCARLATINA. 169 Extensive anasarca, coming on rapidly, is often accompanied by con- vulsions which sometimes prove fatal in their first attack. Brisk purga- tives are useful in these cases by stimulating the intestine to discharge a part of the serosity effused into the cellular tissue. The patient should be placed on the edge of the bed with the legs hanging over it, and ought to have the head propped up by pillows. By these means an impending attack of convulsions may be warded off. But sometimes, from the con- vulsions occurring without the slightest premonitory signs, no preventive means can be attempted. The patient complains of intense headache, im- perfect vision in one or both eyes, ringing in the ears, and very obvious deafness. In these cases scarifications of the inferior extremities may be useful, by producing disengorgement. This object, however, is more suc- cessfully attained by applying very large blisters to the legs-not to the thighs. In seven or eight hours, phlyctaenae are formed : by opening them, an exit is afforded to a stream of serosity, by which discharge the patient is wonderfully relieved, and enabled to tide over the most perilous crisis of his anasarca. When convulsions occur during the disease, give musk in combination with small doses of belladonna. To children between eight and ten years of age, give the musk in doses of from twenty-five to forty centigrammes, and the belladonna in doses not exceeding one centigramme, in the form of a draught. At the same time that you employ these medicines, you ought also to practice compression of the carotids, a means which I have extolled for twenty years, and which has rendered very great services to me and other physicians. The compression requires to be performed with care and according to rule. If one side is more affected than the other by epileptiform convulsion, it is on the opposite side that the compression ought to be most specially applied. If the convulsion predominates on the right side, you compress the left carotid; and if it predominate on the left side, you compress the right carotid. If both sides are equally con- vulsed, you compress each carotid alternately. Of course I am speaking of the common carotids. The compression must be effected in such a way as to interfere as little as possible with the respiration of the child. The compression of these vessels is much easier than you might suppose. You place yourself in such a position as will enable you to compress the right carotid with the left hand, and the left carotid with the right hand. You keep apart the bellies of the sterno-cleido-mastoid muscle; and then, at the same time that you isolate the windpipe, using the back of the distal phalanx, you feel the pulsations of the artery, which is very mobile. You then seize the artery with the cushioned extremities of the fingers, push it a little backwards, and press it against the vertebral column. You imme- diately find that the vessel is compressed, by observing that there is an absence of pulsation in the corresponding temporal artery, and perhaps also by seeing a sudden paleness take the place of the previous red color of' the child's face. Sometimes, also, you have the satisfaction to find that no sooner is the compression established than the eclampsia entirely ceases. You maintain the pressure for fifteen to twenty minutes, first on one artery and then on the other. It is useful to have the co-operation of an assistant in this irksome operation. Mothers, who through affectionate anxiety for their children become so intelligent, may take your place for a time. You may thus, by exercising the necessary patience, in a few hours, in a certain number of cases, put a stop to the convulsions which accompany scarlati- nous anasarca. Serous effusion into the pleurae and pericardium, formidable complica- tions which occur in the last stage of scarlatina, about the same period as 170 MEASLES. anasarca, ought to be treated by a succession of fcirge flying blisters. If the hydrothorax or pericardic effusion be considerable, tapping will be useful. When the pleural effusion is very great, paracentesis is sometimes a necessity after a few days. But it often happens, as I have already ob- served to you, that at the first tapping, even when the effusion is not of older date than ten, fifteen, or twenty days, you may find the serosity lac- tescent, and even containing formed pus: you have then to do with veri- table empyema, a formidable complication which is often curable in young subjects by tapping and frequent iodinous injections; but which, notwith- standing the use of these means, rarely terminates favorably in adults. LECTURE VI. MEASLES; AND IN PARTICULAR ITS UNFAVORABLE SYMPTOMS AND COMPLICATIONS. Normal Measles.-Period of Invasion is longer than in any other Eruptive Fever.- Complications of the Period of Invasion.- Convulsions at the Beginning of the Attack.-False Croup.-Suffocative Catarrh.-Epis- taxis.- Otitis.-Diarrhoea.- Complications of the Eruptive Stage, and of the Last Stage. Gentlemen : In speaking of measles, I shall not go into the subject with that circumstantial detail with which I have treated scarlatina. There is no eruptive disease which assumes such strange forms, and furnishes mate- rials for so much pathological discussion as scarlatina: measles has not the same claims on our attention. I shall, therefore, only trace rapidly the symptoms of measles in its normal form, and specially enlarge upon the unfavorable symptoms and complications which may accompany or follow an attack of that disease. These unfavorable symptoms and complications are unfortunately too little known to young physicians, as I have often had occasion to point out to you. You are aware, gentlemen, that it is not for me in a course of clinical lectures to give you a complete history of measles: that duty belongs to the professor of medical pathology. But I wish to make you acquainted with the complications of this exanthematous pyrexia, explaining to you their mode of evolution by analyzing and discussing cases selected for that purpose in the wards. I must, however, in a sum- mary manner, recall to your recollection the ordinary phenomena of the different stages of measles, which, when they become exaggerated, constitute what we call the complications. From the very beginning of the attack, in the simplest forms of the dis- ease, symptoms present themselves in the mucous membranes of the eye and respiratory passages, which are perfectly well known to those who have once observed them. They consist in lachrymation, injection of the eyes, and slight intolerance of light; in coryza, characterized by a flow of acrid tenacious mucus, frequent sneezing, and often accompanied by profuse epistaxis; and in a severe cough, at times a little hoarse, and at other times very violent and very harassing. The mucous membranes of the eyes, nose, larynx, and bronchial tubes are affected, therefore, from the earliest days of an attack of measles. From the very first day, as in scarlatina, they MEASLES. 171 show the presence of the eruption; and before there is any exanthem on the skin, you see the disease inscribed on the pharynx, tonsils, and veil of the palate. In this stage-the stage of invasion-the fever has not the same char- acter as in small-pox, in which disease, from the very outset of the first febrile symptoms up to the appearance of the eruption, the fever is con- tinuous, always lasting at least till the day on which the pustules come out. In measles, the febrile symptoms follow an entirely different course, which sometimes singularly misleads physicians. Sometimes the fever continues up to the period of eruption ; at other times, it only lasts one or two days, abating very much, and sometimes ceasing entirely on the third day, leav- ing the patient, whether adult or child, with only a slight feeling of dis- comfort ; it reappears, however, with great intensity, on the day the eruption comes out. It begins with slight rigors, recurring from three to six times in the twenty-four hours, which, as they are followed by hot fits and sweat- ing, simulate the paroxysms of the remittent and intermittent fevers, which have a tendency to become continued, and are rather common in the begin- ning of attacks of dothienteritis. In the absence of lachrymation, coryza, epistaxis, and cough, one is very often embarrassed as to the diagnosis, and does not recognize the existence of measles at the beginning of the attack, unless guided by other circumstances than those which belong to the dis- ease itself, such as some of the family having measles, or its being at the time prevalent as an epidemic. The duration of the period of invasion is, therefore, a material circumstance in relation to the diagnosis. The period of invasion is longer in measles than in any other eruptive fever. In scarlatina, on the other hand, it is shorter than in any other eruptive fever, its duration sometimes not exceeding a few hours or a few minutes. Next comes confluent small-pox, the invasion stage of which continues three days, the pustules appearing very regularly at the end of the third or beginning of the fourth day. The cutaneous exanthem of measles does not appear till the fourth or fifth day, and sometimes, even in perfectly uncomplicated cases, not till the sixth, seventh, or eighth day. We have just had an example of this in the workman of twenty-eight years of age who occupied bed No. 18, St. Agnes's Ward. In his case I completely mistook the nature of the disease, as the eruption of measles did not appear till the seventh day: notwithstanding the delay in the eruption, the case was free from any complication. In rare and exceptional cases of scarla- tina and small-pox, when serious complications supervene at the beginning of the attack, the appearance of the eruption is retarded : in measles the general rule is that the duration of the period of invasion is four or five days, irrespective of all complications. During the period of invasion, at the very time when the fever seems to be subsiding, it suddenly acquires a considerable renewal of its intensity. The lachrymation, coryza, and cough, after having been for a very brief space of time in abeyance, return with extreme severity; and simultaneously with this exacerbation of symptoms, very profuse diarrhoea supervenes in the majority of cases. This phenomenon-the simultaneous advent of erup- tion and diarrhoea-belongs essentially to measles, a fact which has not been sufficiently pointed out by authors. The occurrence, though not invariable, is common enough to demand special notice. A child will have from four to fifteen stools in the twenty-four hours. In some cases the diarrhoea is not only serous, but likewise glairy and bloody, caused by an inflammatory affection of the colon, which continues for a day or two. If the diarrhoea continue for more than twenty-four hours, it may, in very young children, 172 MEASLES. become a source of danger, and ought, therefore, to be checked as quickly as possible. The eruption first appears on the face, next day (the fifth or sixth of the attack) it invades the trunk, and on the following day the limbs, after which it is general. I perceive, gentlemen, that I am causing you to take up an erroneous impression. I already hear some of you reminding me, that I have several times shown you in our nursery wards infants in whom, at the second day of the fever of small efflorescences were visible, in situations where the skin was hot and covered with perspiration. On the next day, or the day after the next, there was scarcely a trace of these efflorescences to be found ; and on the regular day of the eruption becom- ing due, it appeared with its precise characters well marked. I must here repeat what I have already said to you beside the cradles of our little patients, regarding the limits of the law of evolution in the exanthem of measles. But in many cases analogous to those which I have just brought before you; the efflorescences mentioned were nothing more than sudorific exanthemata, an eruption not to be confounded with the specific exanthems of measles. So long as the eruption of measles remains bright and blooming [vive et fleurie] the fever continues very intense. This is also the case in scarlatina; but the opposite is the rule in distinct small-pox, in which the fever at once subsides when the pustules appear, to be rekindled, however, on the eighth day of the disease, the commencement of the period of maturation. In measles, then, the fever goes on for two or three days after the appearance of the eruption: it then subsides because the eruption subsides: should it not then subside, there is reason to fear the occurrence of complications. To increased lachrymation, coryza, and cough, there are generally added a little deafness, sometimes acute pain in the ears, in consequence of the Eustachian tubes being affected like the other passages lined by mucous membrane. The eruption in its simplest form, particularly when examined on the chest and abdomen rather than on the face, presents a crop of small, red, velvety elevations, having neither the roughness to the touch nor the wrinkled aspect so often met with in the eruption of scarlatina. They have a certain similarity to the elevations of urticaria: both the dermis and epi- dermis are raised up, and the elevations are even more appreciable by touch than sight. The elevations are generally of unequal shape, and somewhat variable in size, being about as large as a grain of rice or wheat, and so placed as to circumscribe portions of skin free from the eruption. The elevations are at first separate and disappear under pressure made by the finger, to reappear when that pressure is removed: they afterwards become grouped together in irregular patches unequally cutup into little crescents. When the eruption is very confluent, the redness is diffuse and uniform, sometimes rendering the diagnosis difficult. Occasionally, particularly in summer, when patients have been too much clothed and perspire pro- fusely, vesicles appear: they are acuminated, generally contain a puriform fluid, have an inflamed base; and they are much larger than the vesicles which are noted as occurring in scarlatina: in measles a vesicular eruption is exceptional, but in scarlatina it is the rule. The morbillous patches are sometimes so elevated above the cutaneous surface as to have almost a papular character. When this character pre- dominates in the eruption, the case is said to be one of pimply measles [rougeole boutonneuse\. It frequently happens that when the eruption has been very violent, patches of a violet-red color are seen, particularly on the extremities: they MEASLES. 173 are evidently ecchymotic, for they do not disappear under the pressure of the finger like the exanthematic patches. These spots of purpura remain for seven, eight, or ten days after the disappearance of the morbillous erup- tion, leaving behind them greenish-yellow stains. This form of measles is more severe than the other, inasmuch as the eruption is more violent; be- cause it is a general rule in eruptive fevers-in small-pox, scarlatina, and measles-that the gravity of the attack is proportionate to the intensity of the eruption. It is most frequently met with during the predominance of certain medical constitutions of the atmosphere, and it may then become one of the most seriously complicated kinds of measles. Generally speaking, during the periods of invasion and eruption, on aus- cultating the chest, we hear sibilant rales which on the day of eruption very often become subcrepitant, and which, sometimes general throughout the whole extent of both lungs, are accompanied by a degree of oppression in breathing: we have subcrepitant rales, which indicate that the morbillous catarrh already occupies the minute bronchial tubes. This catarrh may be serious from the first, and may go on increasing in severity up to the eighth or ninth day of the disease, then culminating in an affection of intense severity. The subcrepitant rales usually heard at the time the eruption is coming out need occasion no alarm, even though they are very fine, pro- vided the other symptoms are not serious: as in general they either disappear or diminish about the seventh or eighth day, when coarse mucous rales are again heard, then sibilant rales, and finally the sounds become normal. Morbillous catarrh gives rise to a characteristic expectoration. I speak of what is seen in adults and in children of the third age. As you know, infants at the breast, and children under four or five years of age, do not expectorate. The sputa, at first mucous, clear, and limpid, become thick, globular, greenish-yellow, perfectly isolated from one another, swimming in more or less glairy slightly opalescent mucus: they are nummular, as in some phthisical cases. On the eighth day, the eruption begins to disappear: it leaves the face and fades on the trunk. On the ninth day, it has completely left the limbs. The symptoms which then remain are slight ophthalmia, coryza, deafness, and cough, which go on gradually decreasing for seven or eight days, when they totally cease. The period of desquamation now commences. Classical authorities speak of a furfuraceous desquamation consisting of an epidermic dust resembling small scales of bran; but if you minutely examine what is taking place, you will find that there is not one in ten patients who exhibit a trace of this sort of desquamation. However, when the skin is covered with per- spiration-and perspiration is not uncommon in measles-the epidermic scales adhere to the linen, because the exfoliation is exceedingly thin. The desquamation is best seen on the face, because the face, where there is less perspiration than on other parts of the body, is not covered. But even there, the desquamation is often imperceptible: when it is apparent on the face, it is at the eighth day, just as the eruption is beginning to fade, and then you may see the little exfoliations of which I have been speaking. A diagram of the actual range of temperature in a case of measles, ex- actly corresponds with what one would suppose, from clinical observation, to be correct; and it graphically represents to the eye the course of the fever. In the prodromic period, during from one to four days, the tem- perature gradually rises, and does not attain its maximum elevation till the eruption has reached its maximum development. I have already said that the defervescence and the fading of the eruption are coincident: I now add, that when we look at the diagram of the range of temperature, we see that 174 MEASLES. the defervescence is so rapid, so sudden, that in one night the natural tem- perature of the body is established. In severe cases, the defervescence is not quite so abrupt, though still very rapid, and during the subsidence of the fever, slight exacerbations occur from twenty-four to forty-eight hours. You see, therefore, that defervescence in measles is not lagging as in scar- latina: the very opposite is its character. So essentially characteristic of measles is this rapid defervescence, that it may be concluded that the case is anomalous, and that complications arc* going to arise, whenever the tem- perature remains high after the eruption has begun .to fade. The highest temperature observed has been 42.8°. In the researches of Dr. Hugo Siegel, the most common range was between 39.4° and 40.6°. I have now, gentlemen, briefly described the course of normal, simple, regular measles. Having given this rapid sketch, we are now better ena- bled to study the unfavorable symptoms and complications, because they are related to the normal phenomena of the disease. In children, the principal complications are convulsions and false croup; both in children and in adults, catarrh and epistaxis. During the period of invasion, children are frequently carried off by convulsions and catarrh. On the first day, at the very onset of the fever, convulsions often attack children having a tendency to nervous affections. Such subjects are liable to be seized with convulsions when fever is setting in, whether that fever be dependent upon measles, small-pox, scarlatina, an intestinal affection, or a simple pulmonary catarrh, just at the moment of the first rigor announcing the febrile condition. I say just at the moment of the rigor; and I will tell you why I say so. If you reflect on the nature of a rigor, you will perceive that it is really a convulsion. Study it isolated in a particular part of the body-for example, in the lower jaw. The rigor shows itself by the chat- tering of the teeth, caused by alternate contraction and relaxation-more or less rapid-of the muscles which raise the lower jaw; the muscular con- tractions are involuntary and violent. This, as you know, is precisely the definition of a convulsion. When the shivering is general, it is accom- panied by headache, violent pains along the vertebral column, and shaking of the whole body produced by the violent and convulsive jerks of the mus- cles. We have, in fact, real fits of continuous eclampsia, less the cerebral phenomena. How easy then is the transition from a rigor to a fit of con- vulsions! This consideration will lead you to understand why it is gener- ally at the very first rigor of a fever, when the nervous system is in a spe- cially excited state, that convulsions occur. When once the stir-up is given to the nervous system, the first attack is followed by a second, and by suc- ceeding fits, which recur under the influence of any moral or physical ex- citement, or in consequence of a somewhat decided external impression, such as is felt on awaking from sleep, when the nervous system emerges from the state of repose in which it had been wrapped. Convulsions at the beginning of an attack of measles, unless they recur frequently, are not of very serious import. During the period of invasion, two or three fits are not in themselves alarming; but if they go on continu- ously for one or two days, the child may be carried off' in one of them. Unfortunately, medical intervention has a large share in the misfortunes which follow in the train of eclampsia. Nothing alarms a family so much as convulsions; and nothing, I confess, is more frightful. Medical men are sent for in every direction : the practitioner arriving at the end of the crisis and observing only the apoplectic phenomena, loses, sometimes, self- possession, and in the flurry of the moment is liable to make many mistakes. He begins by applying four, six, or eight leeches behind the ear : he sees in the case cerebral congestion, which seems urgently to demand abstrac- MEASLES. 175 tion of blood, with a view to diminish the vascular engorgement. If the patient is a child under four years of age, this treatment will render him anaemic, and so place him in the very condition most apt to produce the evil from which it was intended to save him. Perhaps he orders cold baths, and prescribes cold water to be affused over the head and shoulders of the child when in the bath. The baths and affusions are repeated two or three times during the course of the day. Nevertheless, at this very time, the patient, perhaps, had the* coryza and pulmonary catarrh. A cold affusion, if accomplished in a few seconds, might do no harm under such circumstances; but that cannot be said of prolonged immersion, and far less of the application of ice to the head, which is often prescribed in such cases. The morbillous catarrh, always in itself an affection sufficiently severe to make us endeavor to moderate it, cannot but increase under the influence of such measures. There is, unfortunately, no exaggeration in what I have now said. How many physicians who, though doubtful of the utility of the means they order, yield to the demands by the relatives of the patient for active treatment-for something energetic-for a great demon- stration-in cases where the disease itself is terrible and rapid. The treat- ment by leeches and baths, though a murderous treatment, is so entirely in accord with the theories and prejudices of the public-always ready to dogmatize in medical matters-that were it not for the grave objections to its employment, it would often be difficult to abstain from having recourse to it. The danger is increased by the ignorance of some, and the want of energy of other practitioners. In other cases, persons who, though physicians, are strangers to our art act in a way still more, disastrous. They pour boiling water upon, and surround with cloths soaked in boiling water, the legs of unfortunate children, and so determine in them the occurrence of evils worse than those which they seek to avert. Who has not heard of the frightful accidents, the horrible scalds caused by the medical application of water or some other boiling fluid, which annually result in the death of many children? Who among us has not had occasion to see or to hear related such cases ? But howT oblivious of them are many practitioners when called in to children in convulsions-how they hasten to have recourse to that brutal treatment which I now so emphatically condemn I The contact of towels soaked in boiling water with the skin is much more prolonged than the contact which takes place in accidental scalding. In an accidental scald, the subject is conscious: at the first sensation of pain he proceeds to tear off his clothes, and to beseech others to help him in doing so. But in the coma consecutive to convulsions, the patient feels nothing; and by allowing the scalding cloths to remain so long in contact with the skin those who ought to afford succor kill, when they believe they are saving. When patients sacrificed by this treatment do not succumb under the influence of pain, they are either carried off by the violence of the inflammation, or they sink exhausted by the suppuration. Those who recover, have cica- trices of greater or less depth, which may-according to their situation- give rise to very great deformities. I have several times seen untoward occurrences of this description. Among other examples, I saw one in the person of a man who was at one time my master, and who stood in a similar relation to some of you. Marjolin, in the course of an attack of typhoid fever, fell into a profound coma, to rouse him from which, boiling water was applied to his thighs. He retained to the last the deep scars which resulted from this medication, and which singularly complicated his malady, and long retarded his convalescence. When a child is seized with convulsions at the onset of measles, have 176 MEASLES. the wisdom to wait: abstain from boisterous practice: inquire whether the patient is subject to eclampsia, and whether the fits pass off without the interference of art. If your inquiries are answered in the affirmative, very little treatment will be necessary; for in general, the initiatory convulsions of eruptive fevers subside spontaneously, without our requiring to interfere. Abstraction of blood, prolonged baths, scaldings with boiling water, blisters (which act in a manner analogous to scaldings), and active purging, far from being useful, aggravate the disease; they trammel its progress, retard the period of eruption, and originate complications which are often fatal. There are exceptional cases, in which a first fit of convulsions at the beginning of an eruptive fever is fatal. I have often related the particu- lars of a case which occurred under my own observation in the Necker Hospital. A child of two years of age, who presented no symptoms of cerebral affection, was seized with convulsions, when I was in the very act of examining him. I stated to the pupils then present at the visit, the probable course of the symptoms: I spoke to them of the tonic, which pre- ceding the clonic form would last fifty or sixty seconds, involving the mus- cles of the extremities, chest, and abdomen, and keeping them in a rigid state as at the commencement of an attack of epilepsy. But on two min- utes having elapsed without the rigidity giving way, I began to be alarmed: ere half a minute more had passed, we observed the face become suddenly blue, and the blue color gradually got deeper; when, all at once, the mus- cles became relaxed. The child was dead. However exceptional this and similar cases may be, you may meet with cases of the same kind in your practice. It is essential, therefore, to be able to foresee the chances of bad luck, and to make reservations in an- nouncing your prognosis. I am now speaking only of convulsions at the beginning of measles and small-pox; for convulsions at the onset of scar- latina are not exceptionally but always very unpropitious. You have, gentlemen, very recently seen in our nursery wards, two children, one of whom recovered, after having had all the symptoms of croup, but of false croup, at the beginning of an attack of measles ; and the other died of croup, but of true croup, during convalescence from the exanthematous disease. I cannot tell you how often families are dismayed at the explosion of these unfavorable symptoms during the first four or five days of an attack of measles in which no eruption has yet appeared. The child, after hav- ing in the first instance shown nothing more than the symptoms of a slight catarrh, is suddenly seized with alarming oppression of the chest, accom- panied by a hoarse cough, wheezing inspiration, very laborious respiration, and fever. If there are no cases of measles among those with whom the patient is living, the diagnosis is very embarrassing, and one is apt to be- lieve that the malady is that form of acute laryngitis known by the name of pseudo-croup. This error will be immaterial, unless the practitioner inter- feres, as sometimes happens, in a deplorably hurtful manner. The mistake will not prove injurious, provided he act under the correct conviction that pseudo-croup is seldom a serious affection, and that after some agonizing moments, more terrible perhaps to the heart of the mother than hazardous to the life of the child, the unfavorable symptoms subside. I shall afterwards have to return to the differential diagnosis of acute laryngitis and croup. I presume, however, that it is a subject with which you are familiar. But when you have diagnosed pseudo-croup, take care that you do not allow yourselves to be worked upon by the anxieties of a dismayed family; take care that you do not yield to their very natural impatience; take special care that you do not commit the too common MEASLES. 177 blunder of applying leeches to the neck or the base of the chest. In itself, and in the treatnieot of false croup, this proceeding is not necessarily dan- gerous ; but if the loss of blood should be great-as it may be-it may involve danger. You very often cannot tell in a child when the bleeding will stop ; and excessive bleeding will produce anaemia, which will inter- fere with the natural course of-the'disease, of which the laryngitis was only the precursor. Besides, though the treatment may not in itself be dangerous, it is useless, and for that reason ought not to be employed. Graves, who was not well acquainted with diphtheritic affections, having seen but few cases, pointed out a method of treating false croup, similar to that which I recommended to you : it consists in gently pressing a sponge soaked in warm water-very warm, but not hot enough to scald-under the chin, and on the front of the neck. This operation is repeated in ten or fifteen minutes : it produces a sort of determination to the skin, under the influence of which the symptoms subside in a remarkable manner, the cough at the same time losing its hoarseness. In addition to great efficacy, this medication has the recommendation of extreme simplicity : by it un- aided we can generally remove symptoms, for which without it we should have to administer emetics. My remark only applies to the laryngeal symptoms; for when they disappear, there still remains the bronchial ca- tarrh, the constant companion of morbillous fever, and which, in the prog- ress of the case, may become a threatening feature. Suffocative catarrh is often a serious complication of measles, both in adults and children. About three or four days prior to the development of the eruption, the fever becomes exceedingly violent, oppression of the chest supervenes, accompanied by a moist cough, which, in children, suc- ceeds the hoarse cough of laryngismus stridulus; and auscultation informs us of the existence of subcrepitant rales throughout the whole extent of the lungs. When these symptoms occur at the second or third day of the period of invasion, they generally imply danger; but the subcrepitant rale, if unaccompanied by oppression of breathing, is not so alarming. Capillary catarrh, unconnected with any specific cause, is a very serious malady, particularly in children. It is much more dangerous than lobular pneumonia or pleurisy. There is nothing to cause surprise in the state- ment, that when it is under the dominion of a specific poison, such as the morbillous poison, it is a still more formidable affection. The skin is either almost or altogether free from eruption ; for the whole force of the disease is directed to the bronchial apparatus. Under such circumstances, patients, especially children, sink in three or four days, without any cutaneous erup- tion having appeared. The malady might, therefore, be mistaken for simple catarrh, though really morbillous catarrh. It is often absolutely impossible to establish a differential diagnosis between the two affections, unless we have some characteristic symptoms to guide us, such as epistaxis, coryza, otitis, or lachrymation; and this difficulty is enhanced when we do not know whether there are any cases of measles in the patient's family or neighborhood. In the adult, the form which this catarrh takes is pretty nearly the same as in children. The oppression of breathing is quite as great; on the first or second day, the expectoration assumes a peculiar character: at first it is thin limpid mucus, but about the third day it presents a puriform aspect, the patient expectorating mouthfuls of mucus exactly like pus from an abscess. The sputa are not nummular, and floating in a slightly opalescent serosity like the sputa of normal measles on the seventh, eighth, ninth, and tenth days of the disease, often unnecessarily frighten both patients and VOL. I. -12 178 MEASLES. their physicians; but they are muco-purulent, like the sputa accompanying the suffocative catarrh of the aged. Although the suffocative catarrh of measles is a somewhat less dangerous affection in adults than in children, it must still be looked upon in adults as exceedingly dangerous, and as resisting the most energetic treatment. It generally proves fatal in a few days; -but sometimes the patients go on for a week or more, in which case the capillary bronchitis becomes peri- pneumonia, pseudo-lobular pneumonia, or lobular pneumonia. The latter may be either complicated or not complicated with pleurisy, and when un- complicated in this way, it is much less dangerous. Emetics, with ipecacuanha at the head of the list, antimonials, the pre- cipitated sulphuret of antimony, and a succession of large blisters to the chest, are the therapeutic means to employ in this fatal form of catarrh, and in the forms of pneumonia by which it is followed. Too often they are powerless. Urtication is another means of treatment which may produce immediate benefit in certain cases. When the eruption has not appeared on the fourth day, and catarrhal symptoms are present, I order the body of the patient to be scourged with nettles twice or thrice in the twenty-four hours, so as to produce an abundant eruption on the skin. This urtication is less painful than might be supposed, and produces an immediate effect. Al- though the fever does not subside, the oppression of breathing diminishes gradually as the determination to the skin augments. It is a curious fact that on the second day of this treatment, the nettle-rash, even when the small nettle urtica wrens (more active than the large nettle urtica dioica) has been used, is notably less, and at last, after three or four days, the application produces no effect. This arises from the system having become habituated to the poison, and not from the vitality being so impaired that the organism is no longer acted upon by it. We see precisely the same tolerance of this poison exhibited by country girls who take hold of, and carry in their naked arms with impunity, the very same nettles which at first stung them smartly. Urtication then is of some use in children, and still more in adults, in the treatment of morbillous catarrh. The difference in the degree of efficacy probably depends upon the affection being more severe in the former than in the latter. There are other, though less important complications of the onset of measles. I refer to epistaxis and otitis: the latter is often misunderstood. Epistaxis is an ordinary phenomenon of measles, and when moderate, is certainly not a serious symptom; but it is sometimes so profuse as to en- danger the child's life, or permanently injure his future health. It is treated by applying to the forehead, and causing to be drawn up into the nose, ice and iced water. These measures are good. Astringents, also, prove suc- cessful. But the most successful practice is to inject into the nostrils water as hot as the patient can bear. The injections of strong solutions of sul- phate of copper and sulphate of zinc, a decoction of rhatany, and a solution of perchloride of iron, are excellent haemostatics. The perchloride of iron, however, has the inconvenience of causing the formation of a large coagu- lum which occasions pain : two or three days later, on removing it, to relieve the patient from discomfort, a renewal of the hemorrhage is apt to be pro- duced. But when other means have failed, and the case is urgent, I never hesitate to use perchloride of iron. Sometimes, it is also necessary to have recourse to plugging. The diagnosis of otitis is generally simple in the adult, who can explain what he feels; but it is not so in the child incapable of describing his sen- sations, and only making known his sufferings by cries, leaving us to find MEASLES. 179 out the cause and seat of pain. The excessive pain produces delirium, which is often of a very violent character, and the fever increases. To those not previously instructed on the subject, the formidable array of symptoms will appear inexplicable. When a child is beyond the age of dentition, or when, though not beyond it, has no determination of blood to the mouth; when on careful examination we can find no hernia, no disten- sion of the abdomen, no badly fixed pin pricking, nothing in a word to ex- plain the constant and piteous cries, we may conclude that there is otitis. Almost invariably, in thirty-six or forty-eight hours, this conclusion will be confirmed by suppuration showing itself in a discharge from the ear. It is important to bear in mind these facts, so that you may avoid erroneous therapeutical measures and adopt a useful plan of treatment. You may, therefore, rest satisfied with injecting into the external auditory passage some soothing balsam, or a little belladonna dissolved in water or oil, in place of pursuing a too energetic practice to the detriment of the patient. Belladonna and henbane suffice to calm the paiu ; but unfortunately they are inadequate to prevent the serious evils which otitis brings in its train, and of which I will speak when considering the complications of the third period.* In enumerating the symptoms which accompany the eruption, I stated that it was generally along with it that diarrhoea appeared. It is rarely a serious symptom: and in simple cases, it even seems to constitute a favor- able crisis, when it comes simultaneously with the exanthem on the skin. It would seem that at the moment when the morbid ferment has attained its maximum activity, at the moment when the despumation, (to use Syden- ham's expression) is going to declare itself with all its energy, there cannot be too many emunctories open. The diarrhoeal catarrh, particularly in children, seems an advantageous addition to the coryza, ocular catarrh, and bronchial catarrh. In adults, diarrhoea is an unusual occurrence on the day of eruption. As I have already said, this diarrhoea is sometimes very profuse, the patients having ten or even fifteen stools in twenty-four hours. There is, however, no cause for alarm at such an occurrence, provided the eruption, the fever, and the other symptoms are following the regular course; but if the intestinal flux is exceedingly profuse, and continues be- yond its natural period, and if at the same time the eruption does not come out well, and the eyes have a sunken appearance, there is danger. We must then lose no time in interfering, because in young children so circum- stanced, there is a risk of the case becoming choleriform. Even if the diarrhoea, lasting more than twenty-four hours, is as violent on the second as on the first day, it becomes necessary to interfere. The heroic remedy in such cases is opium. It arrests the intestinal flux ; and in virtue of its diaphoretic powers, favors the development of the exanthem, by acting on the skin. I cannot too earnestly impress upon you the necessity of caution in ad- ministering opium to children. They are so exceedingly sensitive to its action that an infant of one year, or under that age, may be stupefied, and remain in a drowsy state for two days, from taking a single drop of lauda- num, that is to say, the thirtieth of a grain of opium. For so young a patient with the diarrhoea now under consideration, I prescribe half a drop of the laudanum of Sydenham to be given in divided doses, in lime-water, during twenty hours. To prepare the potion, you add one drop of lauda- num to two teaspoonfuls of an infusion of coffee: having thrown away one- half of this mixture of laudanum and coffee, you add to the half which * See page 183. 180 MEASLES. remains, sixty drachms of lime water. This potion ought to be adminis- tered in spoonful doses during the twenty-four hours. It often happens that the morbillous catarrh of the intestines exhausts itself by attacking the large intestine, producing that special form of colitis characterized by tenesmus and glairy, bloody stools. Let me remark in passing that the term dysentery applied to this form of colitis is very inap- propriate. Dysentery is an epidemic disease-specific, contagious, indepen- dent, and special in its character. If it is colitis, it is colitis of an altogether special nature, and quite different from the colitis of measles-as different as the morbillous is from the scarlatinous exanthem, though both eruptions are cutaneous-as different as eczema is from small-pox, though the pustules of both greatly resemble each other. It is very necessary to establish the distinction between morbillous colitis and dysentery, for the former is much less dangerous than the latter. Morbillous colitis generally terminates in spontaneous recovery. When it goes on too long, it can be stopped by administering albuminous injections; or, if a more rapid result be desired, employ an injection of 100 grammes of distilled water containing in solution from 5 to 10 centigrammes of nitrate of silver, or an injection formed by dissolving in the same quantity of water from 25 to 30 centigrammes of sulphate of copper or sulphate of zinc. By such means you will be able to stop the diarrhoeal colic, which comes on at the fifth or sixth day of measles, and is seldom a more serious symptom than the irritation, often rather violent, which affects the upper lip under the influence of the coryza. Between these two symptoms there is a great analogy; they only differ in respect of their seat. Having now passed in review the different complications of the period of invasion in measles-convulsions, false croup, suffocative catarrh, epistaxis, otitis, and diarrhoeal colic, I come to the complications of the second period, called the period of eruption. Strictly speaking, these complications do not belong to the second stage. For example, the capillary catarrh which often accompanies this stage, began with the disease. In many cases, no doubt, it more specially belongs to the second stage, inasmuch as, though it begins to show itself in the first stage, it does not assume a serious character till it bursts forth about the sixth or seventh day of the disease, that is to say, on the second or third day of the second stage, or period of eruption, taking the form of suffocative catarrh, lobular, or pseudo-lobular pneumonia. In a word, simple catarrh is a symptom naturally belonging to the period of invasion, whereas suffocative catarrh, peripneumonic catarrh, and pure pneumonia, belong more to the period of eruption. Peripneumonic catarrh, lobular pneumonia, and pseudo-lobular pneu- monia, the extreme consequences of capillary catarrh, are always the most formidable complications of measles, being much more dangerous than pure pneumonia or pleurisy: it is by capillary catarrh and its consequences that the greatest number of morbillous patients are carried off. When in a case which has gone on regularly till the seventh day, you then observe the eruption grow pale, and next day find an increase of fever, you have reason to apprehend a complication ; and almost invariably that complication will be found to be pulmonary. In the adult, it may be an attack of pure pneumonia; but that is not usual, broncho-pneumonia being the most com- mon form of the pulmonary affection. In children, this broncho-pneu- monia, this peripneumonia is, I may say, the absolute rule, so rare are the exceptions: the inflammation of the pulmonary parenchyma is merely an extension of a previous bronchitis, in which the catarrhal element still pre- dominates. It is all the more important to have clear views on this point in etiology, and upon the nature of the pathological process, that they at MEASLES. 181 once explain the cause of the great danger of this complication of measles. The pneumonic complication nearly always proves fatal in children under three years of age. In an epidemic which I observed at the Necker Hospital in the years 1845 and 1846, out of twenty-four children who had measles, twenty-two died of peripneumonic catarrh : the other two escaped the terrible thoracic complication. This statistical fact enables you to estimate the frightful severity of this affection, which, however, is met with much more frequently in hospital than in private practice. Still, in some epidemics, it commits cruel ravages beyond nosocomial influences; and the physician who considered measles a mild disease till he encountered one of these epidemics, will afterwards modify that opinion. Thirty-seven years ago, when I began the practice of medicine, the first two patients to whom I was called were persons suffering from measles, one a girl of eleven, and the other a female servant of twenty-one years of age. Both sunk under broncho-pneumonia, which in one of the cases was complicated with pleurisy. At that period, I came to the conclusion that measles might prove a serious malady: from that time, many years elapsed without my losing a single case, child or adult, from the disease, and then I met with the disastrous epidemic at the Necker Hospital. This year I have again seen a great mortality in my own private practice, and in consultation with my colleagues, both among children and adults, from morbillous peripneumonic catarrh. Whenever, therefore, about the eighth day of measles, the fever, which ought to subside on that day, continues; when the subcrepitant rales, heard on auscultation from the fourth day of the disease, and which at the time the eruption came out (or at least about the second or third day of the period of eruption), ought to have become less fine, do not undergo that modification, there is reason to fear untoward pulmonary symptoms. The broncho-pneumonia is at first only characterized by general signs, and by the persistency and greater intensity of the fever; but by and by, the bron- chial blowing will exist as a pathognomonic indication of the affection, under which, sooner or later, the patients will succumb. The nature of this complication explains its obstinacy. Catarrh is the most obstinate of all pulmonary affections, as well as the most uncertain in its course. Does not the simplest cold sometimes last longer than a pneu- monia? Do not these inveterate bronchial affections keep people coughing for months, while a pure inflammatory pneumonia is generally a transient illness? We can, therefore, understand the persistency of a pulmonary affection in which the bronchitic element predominates. Apart altogether from the morbillous influence, bronchial catarrh is an exceedingly tedious malady in children. Its custom is to give way for a short interval and then reappear, subsiding and reappearing, it may be, two, three, or four times before final recovery is established at the end of two or three months. Like- wise, after the lapse of two or three months, it may prove fatal. As the pulmonary affection in measles is essentially catarrhal, it is not surprising that the broncho-pneumonia should last thirty or forty days both in adults and children. Independent of catarrh, its essential element, morbillous broncho-pneumonia possesses a virulence of its own, which is the expression of a principle, specific, contagious and septic, which increases its obstinacy and severity. The same obstinacy which characterizes morbillous peripneumonic ca- tarrh is met with in other external manifestations of measles. Thus, the simple ophthalmia, which is part of the disease, may go on for months. This exanthematous ophthalmia, as it has been called by Wardrop, is some- times formidable, leading to granular and ulcerated conjunctiva, phlyctsen- ula, and pterygion. Mackenzie states that he has seen cases in which the 182 MEASLES. eye was destroyed by violent muco-purulent ophthalmia consequent on measles. Such cases, however, are rare. In general, the affection is limited to a more or less decided redness of the conjunctiva, accompanied by intol- erance of light, moderate pain, and lachrymation : but I repeat, that these ophthalmic affections are very obstinate, from the influence of the specific morbid cause on which they depend. Cases of purulent ophthalmia often have their starting-point in measles. The remarks which I have now made on inflammatory affections of the conjunctiva are equally applicable to inflammations of the nasal mucous membrane. Are there not many children and adults who, free before measles from all these evils, have afterwards chronic eczema of the nasal' fossse, eczema invading and causing tumefaction of the upper lip, and some- times extending into the posterior nares, even into the Eustachian tube, where it occasions swelling, which in its turn causes deafness? These inflammations of the eyes and nose may lead to serious conse- quences. When child or adult of scrofulous diathesis is attacked by measles, the latter may, like scarlatina, give development to the already declared or hitherto latent morbid tendencies. These morbillous inflammations may be the starting-point of the evolution of the scrofulous diathesis, which will put its stamp on the lesions of which we are speaking, determining glan- dular swellings going on to suppuration, and leaving indelible cicatrices. These manifestations of diathesis are not the only manifestations of this kind to which measles may give rise. In children who have been rapidly carried off by it, we often find bronchial glands more or less considerably engorged. Just as in scarlatina, we find engorgement of the glands of the neck, and in dothienteritis engorgement of the glands of the mesentery, so in measles we find engorgement of the bronchial glands. This condition is the consequence of the inflammation of the bronchial tubes, just as cervical adenitis is the consequence of the pharyngeal sore throat of scarlatina, and mesenteric adenitis the consequence of the intestinal inflammation in putrid fever. When the catarrhal inflammation of the bronchial tubes is of long dura- tion, and the patient is in subjection to the tubercular diathesis, the glan- dular engorgements assume the.characteristics of that diathesis: on dissec- tion, we find the glands converted into tubercular masses. This remark is applicable to childhood, adolescence, and adult age. At all ages, measles may occasionally become the cause of the development of tubercles, when the individual carries within him the hereditary germ of the disease; and tubercular disease runs its course with much greater rapidity when its start has been accelerated by the exanthematous fever. It is under such circum- stances that phthisis takes the acute form : it is rapid, but it differs greatly from the galloping consumption of typhoid form, regarding which I shall afterwards have to speak to you. I have already told you that measles may determine an attack of otitis. It is generally only a catarrhal affection : but the inflammation may ex- tend from the external auditory passage to the middle ear, whence it may be continued to the mastoid cells and petrous portion of the temporal bone. The situation df the patient is then very hazardous: for caries of the bone may lead to abscess of the brain, and inflammation of the mastoid cells may produce purulent infection. One of your masters, Professor Gosselin, has found that inflammation of the osseous tissue, or more correctly osseous phlebitis, is the most active of all the causes of purulent infection; and this condition exists when there is inflammation of the mastoid cells and tem- poral bone. I am indebted to my former pupil Dr. Peter for the particu- lars of a case which beautifully illustrates what I have now been saying. MEASLES. 183 On the 3d April, 1865, Dr. Peter was sent for to Boigneville, to see in consultation a boy of twelve years of age who was dying from the after-dis- orders of measles. Two months previously, he had had the eruptive fever at one of the colleges of Paris. During his convalescence, his relations re- solved to take him home with a view to hasten his recovery. At that time he had no cough, nor other symptoms of thoracic complication : moreover, he was of a robust breed; and there was nothing to lead to the supposition that tuberculosis was impending. All that remained of his attack of measles was an inflammation of the left ear, from which there was a profuse dis- charge of exceedingly fetid greenish pus. Six days before the consultation with Dr. Peter, the young convalescent had been seized with violent shiver- ing, soon followed by sudden intense pain in the right scapulo-humeral ar- ticulation. From that time he kept his bed, lost his appetite, and had daily paroxysms of fever with repeated rigors. Four days after the attack of pain in the shoulder, he had a similar seizure in the right coxo-femoral ar- ticulation. When Dr. Peter saw the patient, there were enormous swell- ings in the right shoulder and right haunch, and an (edematous puffiness over the chest, abdomen, thighs, and the parts in the vicinity of the affected joints. He could not in any degree spontaneously move the affected joints, and every movement communicated to them by others occasioned frightful pain. He was in a high fever, the pulse beating 160 in the minute : he had dyspnoea, with fine rales disseminated over the chest: and was in a state of constant low delirium. He was, moreover, suffering from jaundice, the date of which could not be ascertained, and regarding which there did not seem to be anxiety. Two facts were elicited by percussion over the liver; viz.: that it was greatly enlarged, and that at certain points it was painful on pressure. Dr. Peter, connecting the jaundice with the state of the liver, the state of the liver with the articular lesions, the articular lesions with the pains which had preceded and the shivering which had accompanied them, concluded that it was a case of purulent infection pand he likewise inferred that there were metastatic abscesses in the liver, perhaps also in the lungs, and that there was unquestionably suppuration in the joints. Without hesitation he recognized as the starting-point of the purulent in- fection, the deepseated otitis, with its associated caries of the mastoid cells and petrous portion of the temporal bone. Everything concurred to justify this induction. There was the character of the suppuration-its profuse- ness, and excessive fetor (so characteristic of osseous suppuration), and its abrupt suppression on the occurrence of the shivering and articular pains. This diagnosis was accepted by the physician in charge of the case, who had, however, at first concurred with a physician of a neighboring town in the perfectly inadmissible hypothesis, that it was a case of acute tubercu- losis of the articular extremities. The unhappy parents, dismayed at Dr. Peter's prognosis, called in my friend Dr. Blache next morning, who made exactly the same diagnosis. The patient died during the day. I entirely concur in Dr. Peter's diagnosis. I feel convinced that there was purulent infection in this case; and making a retrospective review of other cases I have seen, but have not very exact notes of, I explain them in the same way. Be guarded then, gentlemen, in your prognosis, when you meet with deepseated otitis as a sequel of measles or scarlatina: be as- sured that the inflammatory action is not simple, that it derives an excep- tional gravity from the eruptive fever, and exists in a subject whose or- ganism has been thereby seriously impaired. Gangrene of the mouth and vulva occur as sequelae of measles, particu- larly in hospitals appropriated to young children. These affections are well known to the sisters attached to the service of the hospital in the Rue 184 MEASLES. de Sevres: when they have to nurse cases of measles, they take double pre- cautions to secure cleanliness, particularly in respect of the little girls under their charge. When these precautions are neglected, small excoriations are seen on the vulva. In themselves, there is nothing serious in these excoriations, which are produced the more easily that the mucous mem- brane of the genitals is not more exempt than the other mucous membranes from morbillous influences. But if the patient is in the midst of concen- trated epidemic influence, such as too commonly exists in a children's hos- pital, the excoriations on the vulva may become a way of entrance for gangrene. The affection may at first escape but a considerable swelling soon appears at the side of the labia majora and probably extends into the groin. The skin over the tumor is of a bright red color, the sub- jacent tissues are hard, and examination by the touch leads to the diagnosis of a deepseated abscess. On separating the vulva, we discover pultaceous concretions of a whitish, sometimes of a grayish color: they have generally a very fetid odor, and sometimes extend back to the anus. Under such circumstances, there is no time for temporizing: energetic treatment must be immediately resorted to. The day after the appearance of the concre- tions, the cellular tissue may be in a state of gangrene, and the labium sphacelated in its entire thickness. The gangrene may invade the vagina, and even perforate the peritoneum, in which case death rapidly ensues. The danger can only be averted by prompt and vigorous treatment. Cau- terize the parts with fuming hydrochloric acid, nitrate of silver, or sulphate of copper; and if the caustics are not sufficient to stop the progress of the gangrene, you must resort to the actual cautery, then your sole resource. Diphtheritis may sometimes also have measles as its starting-point. When such is the case, it generally assumes a malignant character, whether developed in the mucous membrane of the vagina, or in the folds of the skin, where in children the nature of the skin is so similar to that of mucous membrane; or whether, as is most usual, it appears on the mucous lining of the mouth, pharynx, and nose. Purpura is another serious complication of measles, regarding which I said a word at the commencement of this lecture. It presents itself in a form very different from the morbus hoemorrhagicus of Werlhoff, and very different also from the acute purpura with which we are acquainted. I have only seen two cases of this complication of measles. Fifteen or sixteen years ago I was asked to meet Dr. Coqueret in consul- tation, in the case of a girl of five years of age who had just had an attack of measles. The fever had been constantly accompanied by stupor, which is unusual in this disease. The eruption came out: but the exanthematous patches were of a dark color-that hemorrhagic hue which does not disap- pear under pressure of the finger. On the eighth day, slight delirium super- vened, and epistaxis, which had occurred with usual moderation during the first period, became much more profuse. The relations, alarmed at the nasal hemorrhage, called me in. The child had lost a great deal of blood. We recommended nasal injections of decoction of rhatany, of very warm water, of a solution of sulphate of zinc, and of a solution of sulphate of copper. The epistaxis moderated. After some hours, however, other hem- orrhages supervened : she had haematuria, bloody stools, and haematemesis. Finally, within two days, ecchymotic spots appeared on the back; and the child sunk in a state of extreme anaemia. We did not obtain an autopsy: but judging from what I have seen in the bodies of persons dying under similar circumstances, I think we should probably have found ecchymosis around the kidneys, under the peritoneum, and also perhaps (as is occasion- MEASLES. 185 ally met with) under the coverings of the heart, and under other visceral membranes. It thus appears, that in certain conditions, difficult to appreciate, but in which very probably the epidemic constitution plays its part, the poison of measles may impart a special character to this terrible form of hemorrhage, just as small-pox does sometimes, with this difference, that in black small- pox the hemorrhages generally occur in the first, and in measles, in the last period of the disease. Dr. Chairou in a remarkable work, to which a prize was adjudged by the Academy of Medicine, has given the history of a very severe epidemic of measles which prevailed at Rueil in 1862. It was characterized by the exanthem not having much intensity, and in being accompanied by profuse perspiration, and a vesicular eruption analogous to the miliary rash of lying-in women. Dr. Chairou proposed to give it the name of sweating- measles [rougeole-auette]. For my own own part, I do not believe in such a complication of measles as sweating properly so called, any more than I believe in lying-in women being attacked by miliary fever. However, the Rueil epidemic was characterized by very unusual phenomena. From the first, in addition to epistaxis and vomiting, typhoid complications were ob- served, and at a later period of the attack, thrush, aphthous ulcerations, and ulceration of the periosteum leading to necrosis of the maxillary bones. Numerous abscesses in the face and neck were seen, such as are often ob- served in small-pox and scarlatina. The other mucous membranes were often coated with diphtheritic secretion, and the skin, under the influence of blisters or from other causes, was liable to excoriations. To these symp- toms, convulsions were frequently added, and their occurrence, even at the beginning of the attack, almost invariably foretold a fatal issue. The mor- tality from this epidemic of measles was as great as that resulting from ordinary epidemics of typhoid fever. As I have already stated, the nervous complications of measles generally occur at the beginning of the attack : they may, however, recur in the last stage of the disease, when they are not dependent on the fever itself, but on some superadded cause. For example, when broncho-pneumonia and peri- pneumonia supervene in children who have had convulsions at the period of invasion, these pulmonary affections may occasion a return of the con- vulsions, which are then preceded and followed by cerebral disturbance, characterized by stupor. The fits last for two, three, or four days, or some- times only for a few hours or minutes : they generally carry off the patient. The nervous complications of the last stage of measles, which originate gen- erally in a formidable chest affection, are never met with in infants. Measles, then-the complications of which I have now reviewed-may terminate in convulsions; but it must be remembered that convulsions at the beginning of the disease are not serious, whereas, in the last stage-that is, after the eighth day-they involve the worst possible prognosis. 186 RUBEOLA. LECTURE VII. RUBEOLA. Very different Disease from Measles.-Stands in the same relation to Measles as Chicken-pox to Small-pox.-Does not produce Catarrh of the Macous Membranes.-No serious sequelae.-May attack the same person more than once, and does not confer exemption from Measles. Gentlemen : A great many physicians fell into the same sort of confu- sion regarding rubeola as that which still prevails regarding chicken-pox. Rubeola was once considered a modified form of measles, just as chicken- pox has been looked on as modified small-pox. Although some authors still confound variola and varicella, all agree that there is an essential difference between rugeola and rubeola. Though they admit that there is at first view an apparent similarity between the latter two, they describe rubeola, the exanthematous fever, about which I am now going to say a few words, as a perfectly distinct nosological species. This disease was known to old authors under the various names of rubeola, roseola, and exan- theme fugace: it is called essera Vogelii by Borsieri. Rubeola is, like measles, characterized by an exanthematous eruption consisting of irregular spots, the outbreak of which is almost always pre- ceded by febrile phenomena. The general symptoms which show themselves usually for one or two, and rarely for three or four days, are much less marked than in other eruptive fevers. Sometimes they do not amount to more than a slight feeling of discomfort. Generally, however, the feeling of discomfort is considerable, and is accompanied by well-marked fever, rigors, headache, loss of appetite, urgent thirst, excitement, or, it may be, by great prostration. In very young children it is not unusual for the dis- ease to set in with vomiting, diarrhoea, and convulsions. The circumstances, however, which at once distinguishes rubeola from measles is the absence in the former of catarrh (ocular, nasal, and bronchial), an essential prodromic phenomenon of morbillous fever. The lachryma- tion, coryza, and cough which belong to measles are never seen in rubeola. There is a great difference been the eruption of the two diseases. The rubeolic do not, like the morbillous patches, project from the surface of the skin. The rubeolic patches are paler, larger, more distinct from one another, and more isolated by intervals of unaffected skin : they disappear under pressure by the finger, and immediately reappear when the pressure is removed : they occasion intense itching, and are, to use Vogel's expres- sion, ar dentes et prurientes. They are situated on all parts of the body, but are most abundant on the trunk and limbs. They do not present the regularity of the morbillous patches in the way they come out, their progress, and mode of disappear- ing. Exceedingly fugitive, remaining visible for twenty-four or forty- eight hours, they in some cases disappear, without desquamation and with- out leaving any trace of their passage ; and they disappear and reappear alternately for seven days. When once the eruption has finally disappeared, the malady is at an end, and there is nothing to fear from complications so threatening in con- ERYTHEMA NODOSUM. 187 valescence from measles. Nor are there, as in the latter, any unfavorable symptoms to be dreaded in the prodromic or eruptive stages. Rubeola is the mildest of the eruptive fevers. It is never a serious malady, and always terminates spontaneously without the physician being required to interfere. It has sometimes prevailed as an epidemic, as Frank states; and though the contrary has been held, I believe that it is a con- tagious disease. I do not say that it is contagious in the same degree as measles, but among the various causes of rubeola, I hold that contagion incontestably has a place. The leading fact which enables us to separate rubeola from rugeola, is that an attack of the one does not protect from an attack of the other, any more than an attack of varicella protects from an attack of variola, or of variola from varicella. Again, the same person does not generally contract measles more than once; but one attack of rubeola does not protect from other attacks. Borsieri, indeed, has said that a person who has had it once is more liable to have it again : " Qui semel Us laboravit, facile iterum pluriesque prehenditur." Persons of all ages and both sexes take rubeola; but women are more susceptible to it than men, and children are more susceptible that either A hot season, or to speak more correctly, a high temperature, by exciting to copious perspiration, has a great influence upon the production of the rubeolic exanthem. I shall have occasion to return to this subject when I specially discuss the question of sudoral eruptions. I will then tell you how to distinguish the varieties of rubeola occurring in the course of other diseases. For the present, I will only remark that syphilitic rubeola can- not be included among them. Nature, pre-eminently specific, has placed a special stamp upon tbe venereal disease of which a form of rubeola is a characteristic manifestation : the course and duration of rubeola syphilitica point out that it is not a variety of the exanthematous fever I have been speaking of, but an affection belonging to another nosological group. LECTURE VIII. ERYTHEMA NODOSUM A Specific and Separate Disease.-Successive Eruptions.-Articular Pains.- General Symptoms-A Possible Manifestation of the Rheumatic Dia- thesis. Gentlemen: You will only find a few lines devoted to the subject of erythema nodosum [erytheme noueux] in your pathological text-books. Au- thors seem only to mention it, that it may be remembered as one of the principal varieties of erythema, the whole history of which they give in one short chapter. Their descriptions appear to me insufficient; for the malady, a case of which I am going to show you in the wards, deserves to occupy a much larger space in nosological manuals. Correctly speaking, and notwithstanding the generic title by which it is known, and to which for want of a better name I adhere, erythema nodosum in no more a variety of erythema than small-pox is a variety of ecthema, although, considered by itself, the variolous pustule often resembles, and 188 ERYTHEMA NODOSUM. may be mistaken for, a pustule of erythema. Erythema nodosum is a spe- cific and separate disease, which manifests itself locally by characters so precise as not to admit of being mistaken. It also presents a group of gen- eral symptoms necessary to be taken into account. They almost always precede the appearance of the erythematous eruption, and are no more de- pendent upon the local cutaneous affection, than the prodromic fever of small-pox or measles is subject to the influence of the eruption which is going to come out. The local manifestations of the erythematous eruption seem so very well known, that it might be sufficient to indicate them in a few words. I think, however, that it will be useful to describe them in detail. Any one of you will be able to recognize at a glance the spots more or less regularly oval, elevated towards the centre, the size of which varies from that of a few mil- limetres to two or three centimetres, of the diameter of a pea, a hazel-nut, or even a walnut. They project above the skin, forming real knobs or nodes. They rapidly increase in their elevation above the skin, and be- come small hard tumors of peculiar aspect. They are circumscribed in such a way as to look as if their base was set in the thickness of the skin and cellular tissue, and as if they could be seized between the fingers. On their first appearance, they are of a red color, which is the brighter the less the distance is from the centre, and this coloration extends beyond the nodosity. Passing from red to violet-red, it afterwards acquires a yellowish ecchymotic tint, or, gradually fading, gives place to a bluish tint, most decided towards the circumference of the nodosity, and easily disappearing under the pres- sure of the finger. I have never seen these tumors pass into a state of sup- puration, although on pressing them I have felt a sensation of deepseated fluctuation: in a few days spontaneous resolution has taken place. Accord- ing to Professor A. Hardy, however, erythema nodosum may become chronic by the appearance of a succession of eruptions during several months, or even, it may be, during one or two years. When the disease takes this chronic form, the nodes on the legs sometimes become elongated, and then soften and ulcerate. The ulcerations are round, excavated, and of a grayish color at the bottom: they resemble syphilitic ulcers. The attentive obser- vation of the patient, the existence of non-ulcerated nodes, and rii exami- nation of the history of the case will prevent you making an error in diag- nosis. This unusual aspect of the disease, this chronicity of erythema nodosum whether accompanied or not by ulceration, according to my col- league of the St. Louis Hospital, is dependent on a scrofulous taint. I dare not affirm, gentlemen, that the chronic erythema which I have described to you is the same disease of which M. Hardy speaks. Possibly, an anoma- lous cutaneous affection suggested to that able physician an opinion which I hesitate to adopt. The favorite seats of erythema nodosum are upon the legs and arms, in situations where the skin is separated from the bone by a very thin layer of soft parts-on the forearm at the posterior edge of the internal aspect of the ulna, and on the leg on the inner aspect of the crest of the tibia. It is in this latter situation that the characteristic nodulated form of the tumors is most conspicuous. So sensitive to pressure sometimes are the nodes over the tibia, even when lightly pressed, that the patients cannot tolerate the pain caused by the weight of the bed-clothes. The nodes are usually dis- seminated, separate [discretes, distinctce], and few in number; but at other times, they are more numerous, and in some cases become confluent from new nodes springing up beside former ones, and the two sets getting blended together, so as to form patches of greater or less size, of a more or less bright ERYTHEMA NODOSUM. 189 red color, with irregular edges, somewhat resembling erysipelas, in their general appearance. Although erythema nodosum has a predilection for the situations I have mentioned, it not only appears on all parts of the skin, but also on the mucous membranes. In a woman, whose case I am about to recall to your recollection, you saw an erythematous patch on the conjunctiva of the left eye. This patch on the conjunctiva is a pimple rather than a true node; and the spots on the thighs, arms, neck and face in erythema nodosum are generally papular. By and by, when I come to speak of papular ery- thema, I will recall to your recollection the differences between the two forms of erythema, mentioning at the same time the phenomena common to both, and by which they seem to be assimilated ; but I will now antici- pate what I have to say by remarking, that it is very rare to see a case of erythema nodosum without pimples, while nodes are seldom seen in papular erythema. The eruption does not always all come out at once, but sometimes in successive crops, fresh nodes appearing in succession before their predeces- sors have faded. New crops go on appearing at longer or shorter inter- vals, the period of eruption being sometimes thus prolonged to twenty-one days. The duration of the acute stage of the disease is from one to twen- ty-one days. So long as the general symptoms continue, and the fever does not abate, the appearance of new spots may be expected. I shall now state what took place in the case to which I have just alluded. The patient, a woman of 57 years of age, was admitted on the 15th December to bed No. 25 bis in our St. Bernard Ward. She said that she had been ill for ten days : she complained of general discomfort, head- ache, articular pains in the left shoulder, and want of appetite : the tongue was red, the skin hot, and the pulse 100. I detected erythematous spots on the right thigh, and internal aspect of the right elbow. No abnormal sound was heard in the heart on careful auscultation. Next day, a spot appeared on the right arm, and a new spot on the left, in the same situa- tion as the other. In respect of hardness, the spots resembled syphilitic gummee. On the 17th December, the eruption appeared on the external aspect of the left thigh, and the fever continued unabated. On the 18th, the spots were still more abundant, and some of them were papular. The tongue, red at the point and edges, was covered with a whitish fur. The pulse was still 100, and the skin hot. On the 20th December, we observed spots on both arms over the inferior portion of the ulna. On the thighs, the spots were confluent; and round one of the knees, the confluence was so great as at a first glance to suggest erysipelas. This was the day on which we saw an erythematous spot on the conjunctiva, at the outer angle of the left eye. There was some abatement of the fever: but on the 22d, it had regained its former intensity. On the same day there was a fresh crop of spots; and the patches on the right thigh, some of which were as large as a five-franc piece, were bright red, and very painful. The pain in the shoulder was more violent than when my attention was originally directed to it, and it was increased by the slightest pressure. The ery- thematous spot on the eye had faded, and there only remained in its place a little injection of the conjunctiva. On the 23d and 24th, new spots appeared on the legs : on the 24th, however, the fever subsided consider- ably, and the pain in the shoulder greatly diminished. No fresh spots appeared after the 25th. From that day the patient felt much better, and convalescence began. She left the Hotel-Dieu, completely recovered, during the first week of January. 190 ERYTHEMA NODOSUM. Convalescence, gentlemen, is sometimes tedious, almost as protracted as in some putrid fevers. The articular pains which precede and accompany the eruption seem to me to be characteristic of erythema nodosum. The general symptoms con- sist in a universal feeling of discomfort, in lassitude and aching of the legs, headache, want of appetite, and a loaded state of the digestive canal; and in fever more or less severe during a prodromic period which varies in du- ration from one to five days. When once the eruption is accomplished, recovery generally takes place in one, two, or three weeks; but again I repeat, that the duration of the malady may be much more protracted, and that so long as the general symptoms continue new eruptions may be looked for. Articular pains are complained of almost at the same time that the gen- eral symptoms set in ; they sometimes continue as long as the eruption lasts, and even after it has disappeared. They come on spontaneously, are aggra- vated by pressure, are sufficiently acute to hinder movements, and some- times even entirely to prevent them, as was the case in a young woman in our St. Bernard Ward, who kept her fingers flexed from inability to extend them. They are sometimes limited to a single articulation, and in other cases, as in the young woman just referred to, they extend to all the joints. The pain is sometimes as acute as in pure rheumatism ; but I have never seen redness or swelling in the situation of the affected parts; nor have I ever found signs of cardiac lesion. The existence of these articular pains seems to indicate that erythema nodosum is of the nature of rheumatism. The best authors have pointed out the mutual relations of rheumatism and erythema nodosum. This has been done in France by Dr. Bouillaud,* and in Germany by Professor Schcenlein, who has given to erythema nodosum the name of rheumatic purpura. Dr. Bazin, an accomplished physician of the St. Louis Hospital, has not hesitated to place it at the head of his pseudo-exanthematic ery- thematous arthritides; and Rayerf has described a papular erythema oc- curring in persons suffering from acute rheumatism, which to the eyes of Dr. Bazin is erythema nodosum itself. I was formerly in the habit of attaching a great deal of importance to the articular pains, and tried to subdue them by giving preparations of sulphate of quinine, or veratria. Afterwards, from a study of the natural course of the disease, I perceived that they generally yielded without the intervention of art, and I then restricted my treatment to keeping the patients in bed, and telling them to avoid chills. These hygienical means and cooling drinks now constitute my w'hole treatment of these pains. When the stools are slimy, and indicate a loaded state of the digestive canal, I endeavor to correct that state by administering mild purgatives. Erythema nodosum is not a common disease of children, but I cannot exactly say that it is rare among them. One of my pupils lately told me that he had seen it in two brothers, one aged two and a half, and the other four years of age. * Bouillaud: Traite Clinique du Rhumatisme Articulaire. Paris, 1840. f Bayer: Traits des Maladies de la Peau. Paris, 1835. ERYTHEMA PAPULATUM. 191 LECTURE IX. ERYTHEMA PAPULATUM. Differs from Erythema Nodosum in the Form and Seat of the Eruption, and in the Severity of the Symptoms.-Rheumatic Character. Gentlemen : Although erythema papulatum [erytheme papuleux] and erythema nodosum have obvious affinities with each other, I should not wish you to take up the idea that they are identically the same disease. They have undoubtedly something in common, just as small-pox and chicken-pox have something in common; but in my opinion they possess characteristic differences which allow us to regard them as two distinct species. Recall, gentlemen, the marked difference between the physiognomy of disease in two women whom you saw with erythema nodosum, and in three patients with erythema papulatum, two of whom are in the St. Ber- nard Ward, and one in the St. Agnes Ward. The patients with erythema nodosum presented, relatively to the other group, very mild symptoms, though the cases were severe for the affection; while the three with erythema papulatum had very formidable symptoms, so formidable in one of them as to occasion death. Do not suppose, gentlemen, that the disease is formid- able in proportion to the intensity of the eruption, as is the case in small- pox and scarlatina. The forms, the seat, and the mode of evolution of the eruption are so various as to establish the diversity of the nature of the two diseases. Again, erythema papulatum is accompanied by serious pul- monary lesions, and sometimes by articular rheumatism and endocarditis, whereas erythema nodosum has no such accompaniments, or at least is not attended by pulmonary lesions. You will easily understand this distinction when I recall to your recollection the history of cases which you have had an opportunity of studying with roe in the clinical wards, and which you will be able to compare with the history of cases of erythema papulatum. Let me first recapitulate the case of the man who occupied bed No. 24 in St. Agnes's Ward. He was an assistant-cook, who had lived in Paris for the four months preceding his attack, during which period he had enjoyed good health. He was admitted into hospital on a Friday. On the previous Sunday, he had felt, as precursory symptoms, stiffness and pricking in the eyes. He also experienced pains in the wrist and joints of the middle finger, which on the following day became so violent as to interfere with the movements of the parts affected, to the extent of preventing him from opening and shutting the hand. In the evening of the same day, he had pains in the knee. There were, however, neither fever nor loss of appetite. From the Sunday also, he had perceived on his hands an eruption of uniform redness. On the Tuesday, the backs of both hands, the cheeks, and the forehead were covered with pimples, and there was some fever. Upon his admission into hospital, I observed this papular eruption, upon a ground of a winy-red hue, raised above the parts of the skin which were not affected. Besides some pustules of acne on the inferior extremities, we saw a small patch of ery- thema nodosum on the left leg: this patch was painful. In no other situa- tion than those named did we find any trace of eruption, except in both 192 ERYTHEMA PAPULATUM. conjunctivae, the sclerotics of which were injected with livid red. The edges of the eyelids were also red. On the Thursday following-the seventh day after admission and the twelfth from the beginning of the attack-I observed a little obstruction of the lungs characterized by cough and mucous sub- crepitant rales in the posterior part of the base of the left lung. The patient, nevertheless, asked for food and did not remain in bed. Two days afterwards-on the fourteenth day of the malady-the erythematous patches were much paler, but new pimples had come out in the situations in which they had been first seen. For forty days, his general condition was very unfavorable, and the fever continued. There were five or six successive eruptions. The patient became exceedingly thin; and on the sixtieth day from his seizure, he was as weak as if he had had an aggravated attack of dothienteria. In connection with the case now detailed, I will relate that of a woman who lay in bed No. 11 of St. Bernard's Ward, in whom the disease proved rapidly fatal. Her age was sixty. She had long suffered from pulmonary emphysema, and on admission had bronchitis accompanied by fever, and a state of stupor which to me did not seem to be dependent on the state of the bronchial tubes. For several days, the chest was auscultated with very great care, with a view to discover whether there was any point affected with peripneumonia. Three days after admission, erythema nodosum was detected on the legs and erythema papulatum on the backs of the hands. This woman, by occupation a washerwoman, had had several attacks of rheumatism, and it was through exposure to cold and damp that she had contracted the catarrh which brought her to the hospital. The bronchitis soon became general, and on the twentieth or twenty-first day terminated fatally, having become complicated with double hypostatic pneumonia. On examination after death, we found sero-sanguinolent engorgement of the lower third of both lungs, and a muco-purulent fluid in the minute bron- chial tubes. You have lately watched the evolution of erythema papulatum in a woman who occupied bed No. 33 of the same ward, and whose life was in great jeopardy for more than fifteen days. I regard her case as one of the most conclusive I have met with in support of my opinion, that erythema is essentially a constitutional affection. Here are the facts drawn up by M. Dunton tpallier: "A young woman of thirty-eight years of age, who, though a rheumatic subject, had enjoyed very fair health for several years, was admitted to the St. Bernard Ward with all the symptoms of an attack of fever. She had general prostration, lassitude, pains in the legs, quick pulse, foul tongue, nausea, sweating, and constant headache. The patient had had these symptoms for several days, but there was nothing in their duration, nor in the predominance of any one of them, to lead us to suppose that the case was an eruptive fever; nor was there any ground for believing that an organic lesion existed. She merely stated that some days before she came into hospital, she had had pain in both knees. On the day of her admis- sion, there was no trace of articular swelling, and no joint was the seat of decided pain; nevertheless, the persistence of the sweating and fever, com- bined with the dull white color of the skin, suggested rheumatic fever. There was from her first day in hospital, moreover, a slight blowing sound audible over the apex of the heart. The question arose: Was this abnormal sound the result of a lesion originating in previous rheumatism, or was it de- pendent upon existing subacute endocarditis? She had neither palpitation nor pain in the region of the heart. Not finding anything to account satis- factorily for the continuance of the general symptoms for so many days, and ERYTHEMA PAPULATUM. 193 having abandoned the hypothesis that they belonged to an eruptive fever, I examined the skin, to see whether I could discover any trace of an ephem- eral eruption. The examination was not without results: on the arms and forearms, as well as on the thighs and legs, I observed an eruption of papules of various sizes. On the external aspect of the middle of the left arm, they formed slightly elevated confluent patches: they were of a rosy color, soft to the touch, and disappeared on slight pressure, reappearing on the pressure being removed: it was observed that the papules were in sev- eral places grouped in such a way as to present the appearance of semicir- cles. Similar isolated patches were seen on the palmar aspect of the left arm and forearm. The patient was not aware of the existence of the erup- tion, which had occasioned neither heat nor itching. On the anterior and external lateral aspect of the thighs and legs, there were a very few' similar patches, which were but little elevated. She was astonished when we pointed out to her nodulated spots on the anterior surface of the leg; these spots were pale red, elevated above the surface of the skin, and rested on a bump as large as a small filbert-nut: here we undoubtedly had erythema nodosum. On the following days successive eruptions appeared, and they wTere beyond the possibility of doubt erythematous. In point of fact, new papules and new bumps appeared in crops, just as successive crops of eruption come out in chicken-pox on the arms and legs. The bumps were confined to the legs and one of the thighs. The erythema papulatum was particularly well marked in the left arm, in the situation of the insertion of the deltoid mus- cle: several crops of papules appeared there successively, and after three or four crops the papules were as red and raised as on any other part of the body. Simultaneously with each erythematous eruption, there was a febrile exacerbation, accompanied by rheumatic pains in the knee-joints, wrists, ankles, hands, and feet. The skin continued moist. Auscultation, which, from the day of the patient's admission, had revealed the existence of sub- crepitant rales throughout the whole of the posterior part of the chest, soon afterwards disclosed double pleurisy, unaccompanied by stitch in the side, and attended by very little cough. Over the inferior angle of both scapula;, a blowing sound and egophony w'ere heard. There was also effusion on both sides which did not ascend higher: it was more persistent on the left than on the right side. The fever lasted for fifteen days after her admis- sion. For the last two days, however, of that period, it was more moderate, the perspirations were less profuse, and there were no longer articular pains. There wras no fresh eruption, and the old papules had entirely disappeared. The bumps were no longer appreciable to the touch, and no traces of their former existence remained except ecchymotic staining of the skin. The appetite had returned, the tongue was good, and the double pleurisy was undergoing resolution." Upon comparing with each other all the facts in this case, you will find that they possess a common physiognomy. There was violent and contin- uous fever, profuse perspirations, particularly at night, a very formidable pulmonary affection, and an illness lasting much longer than could have been anticipated from the first symptoms. I do not wish, gentlemen, to omit stating some circumstances which seem to tell against my opinion. As I mentioned to you already, I have often met with erythema nodosum and erythema papulatum differing from each other, but have never seen a case of erythema nodosum in which there were not numerous papules, and I have sometimes met with true nodes in erythema papulatum. Again, in both we meet with articular pains, and even endocarditis, though not so frequently in erythema nodosum as in erythema papulatum. I do not consider, however, that because these phe- VOL. I -13 194 ERYTHEMA PAPULATUM. nomena are common to both diseases, both are, therefore, identical. It is no more necessary to believe that, than to hold that scarlatina and small- pox are identical because a scarlatiniform eruption has been seen at the beginning of an attack of modified small-pox. There is unquestionably a great similarity between the ataxo-adynamic symptoms of typhoid fever and of pyaemia, but no one will deny that these two diseases are essentially distinct and different. In the cases which I have laid before you, it is difficult to avoid seeing a confirmation of the views of my colleague at the St. Louis Hospital, Dr. Bazin, regarding the arthritides. According to him, both erythema nodosum and erythema papulatum are arthritic affections. Though they differ in form, he holds that they are identical in essence; they both spring from one common diathesis-the arthritic. This doctrine, eminently medical, explains our meeting with in the same patient, on the one hand, evidence of previous articular rheumatism, and on the other the coexistence of the cutaneous eruptions with cardiac and pulmonary affec- tions. It is not then erythema papulatum which is formidable, but the diathesis of which it is an expression. There are, however, cases of erythema papulatum exceptionally mild, which may in this respect be compared with cases of erythema nodosum. There is at this very moment, in bed No. 33 of the St. Bernard Ward, a woman of fifty years of age, in whom erythema papulatum is very con- fluent on the face and neck, and still more on the hands and forearms, but who is without fever, articular pains, gastric or pulmonary ' symptoms. Hence it is evident that there are degrees of severity in erythema papu- 1'atum, as in any other eruptive disease; but this does not in any way go to prove that, as a general rule, one of the two is a much more serious malady than the other. Gentlemen, erythema papulatum, like erythema nodosum, declares itself by general symptoms-by general discomfort, fever, and a saburral state of the digestive canal. These prodromic symptoms are usually met with, though they were absent in our patient in the St. Agnes Ward. The dura- tion of the prodromic period is variable, and lasts from one to five days. Along with these general symptoms, there set in, as in erythema nodosum, articular pains, which are sometimes of such severity as to impede, or even completely prevent, the movements of the body: these pains continue during the eruptive period, and are often prolonged till after its conclusion. Endocarditis occurs in some cases, as you have had an opportunity of ob- serving. Erythematous rheumatism, like scarlatinous rheumatism (which is much less severe and less obstinate than acute articular rheumatism), often assumes an exceptionally intense form. The eruption consists of patches of a winy redness, sometimes placed near each other, and sometimes disseminated; they may be either quite round, or they may be of irregular shape. These patches, constituted primarily by small tumors, painful to the touch, fade, flatten, and pass from a red to a violet-red color. M. Hardy says that the patches are sometimes complete circles surrounding portions of sound skin. The eruption ends with slight desquamation. Vesicles have been observed on the patches ; their duration is very ephemeral; they dry up quickly, leaving no trace behind, whether they burst or whether they disappear in consequence of their serous con- tents being absorbed. The eruption is often indolent. It may be accom- panied by a feeling of heat, burning, or itching. It is a characteristic circumstance that the eruption has a preference for the hands, forearms, face, and neck. It is less frequently seen on the inferior extremities, differ- ing in this respect from erythema nodosum, which prefers the continuity of the limbs, and particularly the parts where there is only a very thin sepa- ERYSIPELAS. 195 ration between the skin and the bone. Erythema papulatum lasts for fifteen or sixteen days. The treatment ought, as in simple erythema nodosum, to be restricted to precautionary and hygienical measures. When the articular pains are not severe, no interference is called for. When the thoracic complications assume a formidable character, and when the rheumatism becomes general and invades the heart, the treatment required will just be that which is appropriate in cases of pleurisy, broncho-pneumonia, or polyarthritic rheu- matism. LECTURE X. ERYSIPELAS; AND IN PARTICULAR ERYSIPELAS OF THE FACE. Pathology of Erysipelas.-Almost always an Exciting Cause, independent of Individual Predisposition and General Cause.-May Supervene in the Course of Epidemics.-Severity increased by Traumatic Influence.- General Symptoms dependent on Inflammation of Wound and Lymph- atic Vessels.-Delirium has not the Signification attributed to it in Erysipelas.-Erysipelas sometimes Contagious.--When not a Compli- cation of another Disease is a Mild Affection which Subsides Spontane- ously.- The Treatment ought to be Expectant. Gentlemen : We have at present several patients affected with erysipe- las-a young girl in bed No. 6 of the St. Bernard Ward, a young woman of twenty in bed No. 10 of the same ward, and a young man between twenty- five and twenty-six years of age, occupying bed No. 8 in the St. Agnes Ward. The manner in which these three persons were seized was very nearly similar, and in all of them the erysipelas of the face has assumed the same form. In bed No. 4 of the men's ward we have seen a fourth patient with erysipelas; but his case has been invested with special interest in consequence of the course which the disease has taken. This man, from the date of his admission, had a very violent sore throat,, with consequent affection of the submaxillary glands. At my first exami- nation of him I predicted that by the next visit the case would have declared itself as erysipelas of the face; and the event justified my prog- nosis. My opinion was founded on the presence of certain phenomena, to which I directed your special attention. Three days previously, the patient had experienced exceedingly severe pain in the throat; next day, the sore throat was well marked; and on the day following, the severity of the pain had increased, while at the same time intense fever set in and a large glandular swelling formed at the angle of the lower jaw. On depressing the tongue and examining the pharynx, we found a vivid redness of the uvula, veil of the palate, and pillars of the tonsils. From these symptoms, I came to the conclusion, that the case was either catarrhal sore throat, or erysipelatous inflammation of the pharynx. But as catarrhal sore throat is in general not nearly so painful as erysipelas of the pharynx; as the swelling was not so great, as the redness was less vivid, as the fever was more severe and the cervical glands more swollen than is usual in the former, my ultimate diagnosis was erysipelas. With my diagnosis thus 196 ERYSIPELAS. settled, T had to wait till the malady should proceed to the nasal fossae, and by that route reach the face. Well! the erysipelas, which during the night had begun to appear at the orifices of the nostrils, forthwith extended to the nose; next morning, the pain of the throat and the redness of the pharynx had disappeared, and the malady pursued precisely the same course which we see it follow when we watch its evolution on the skin. From the nose, it extended to the cheeks, from the cheeks to the eyelids and forehead, whence it advanced to the hairy scalp, and so on it proceeded, till it had made the circuit of the head, resting from two to four days in one situation and then invading the adjoining place. It is very important to be acquainted with this line of march which erysipelatous inflammation follows. Ten years ago, my friend Dr. Gubler was the first to point out that erysipelas of the face is only a propagation of the disease from the pharynx,* and not a metastasis as had before that been often repeated.f The propagation may proceed, as was also shown by the same able physician, in an inverse order; that is to say, the erysipelas may begin in the skin, and proceed from it to the mucous mem- branes. Erysipelatous inflammation of mucous membranes must not be confounded with other kinds of inflammation to which they are liable. In a practical point of view this is very important. No doubt, I shall have occasion to return to this topic in the course of my lectures. But to-day, gentlemen, the subject on which I have to address you is erysipelas of the face. Do not suppose that it is my intention to give you a complete history of the disease; for that you will find in the text-books which are in the hands of all of you. Chomel and Blache, in the Diclionnaire de Medecine, and MM. Hardy, Behier, and Valleix, in their treatises on internal pathology, have given exhaustive descriptions of erysipelas. I only propose, therefore, to speak at present upon some specialties in its pathogeny and treatment. Surgeons for the most part are agreed that when erysipelas appears in the wards of a surgical hospital, its presence is dependent upon traumatic influences. A patient, for example, after having undergone a trifling operation, such as the opening of an abscess with the lancet, or the making of a small cut in the skin for some other purpose, is, after an interval, affected with general discomfort: the glands in the vicinity of the wound become enlarged, those of the groin for instance, when the wound is on the inferior extremity, and those of the elbow and axilla, when it is on the hand. The erysipelatous redness soon appears. In such cases, the cause of the affection is evident: everybody readily recognizes its mode of develop- ment : the existence of a predisposing cause either in the individual or in the circumstances with which he is surrounded is admitted: the existence is admitted of an epidemic constitution of the atmosphere in consequence of which the most insignificant operation, at other times unattended by any such risk, is immediately followed by erysipelas. But the affection so arising is always traumatic, and you must be careful to distinguish it from what is called medical erysipelas. Many physicians are of opinion that medical erysipelas is not under the law to which surgical erysipelas is subject. According to Chomel and Blache, erysipelas is never the result of an external cause, and they say * Gubler : Societe de Biologie, 1856. f Upon this subject, see the more recent researches of V. Cornil, entitled, Observations pour servir a 1'histoire de 1'Erysipele du Pharynx" [Archives Gene- rates de Medecine, 1862]; and J. ClURE : "De 1'Erysipele du Pharynx." Inaugurate.] Paris, 1864. ERYSIPELAS. 197 that if sometimes an accessory cause contribute to its production, it is only in a secondary manner. I think it is nearer the truth to say, that in the immense majority of cases both classes of causes are in operation. It is so, in the circumstances to which I have just alluded, when during an epidemic, cases of erysipelas seem to arise spontaneously; that is to say, without any appreciable exciting cause. Such of you as have attended the surgical wards know', that one or two years may elapse during which an attack of erysipelas is an unusual occurrence after an operation however serious, and that at other times, the surgeon cannot make the slightest use of the bis- toury without exposing his patient to this risk. This is the present state of matters. There is also now prevailing one of the severest epidemics of puerperal fever which has in recent times desolated the Maternity Hospital, where sixty patients have died within ten months from this terrible pesti- lence. At the very time when prudence compelled the physicians of that establishment to shut it up, and send the women to be confined in the other hospitals, erysipelas broke out in a severe form in a great many of the sur- gical services, among those who had wounds. The coincidence of puerperal fever and traumatic erysipelas has been pointed out long ago, and Graves has taken up the subject with precision in his clinical lectures: but it is to the Clinical Hospital of the Faculty of Medicine of Paris that we must specially refer for proof of the occurrence of this coincidence, as there, under the same roof, separate wards exist for surgical patients and for lying-in women.* It is, therefore, an incontestable fact that under certain atmospheric con- ditions-under the influence of an unknown something in the air-indi- viduals become disposed to take erysipelas from slight causes which would not have produced it at other times. Graves believes in this, and also in contagion. This is a subject to which I shall by and by return, but I may now remark, that even when contagion operates, immediately exciting causes generally play a part not hitherto sufficiently appreciated. Observe with attention, and you will see, that the erysipelas described under the names of medical and non-traumatic (in contradistinction to that termed surgical and traumatic), has almost always a starting-point, which though it cannot strictly speaking be called a wound, is at least a lesion-a very slight lesion it may be in some cases. In three of our patients, this was placed beyond doubt. The young girl of bed No. 6 St. Bernard's Ward had a suppurating pimple at the angle of the eye, which she scratched, and so excited in it an increase of inflammation. From this little breach of continuity erysipelas started, which progressively invaded the cheeks, forehead, and hairy scalp. The woman occupying bed No. 10 had long had eczema of the nose, and there it was that the erysipelas commenced. From the nose, it extended to the eyes, face, and hairy scalp; in which latter situation it is now' begin- ning to show itself, after having becoming extinct in the other places. In the young man occupying bed No. 8 of the St. Agnes Ward, erysipelas took the same course, having had likewise eczema of the nose as its exciting cause: and this is the third erysipelatous attack which this young man has had, the starting-point in each of them being his chronic eczema of the nose. Again, I say, therefore, observe carefully the cases you meet with, and in nearly every one of them you will find a small lesion of the integuments at some point on the face, such as the corner of the eye, the nose, the lips, * See the report of the long discussion on puerperal fever in the Academy of Medicine: "De la Fievre de sa Nature et de son TraitementParis, 1858. 198 ERYSIPELAS. behind the ear, or in the hairy scalp. This you will find in many cases to be a herpetic ulceration of the face, or of the mucous membrane of the throat; and sometimes inflammation of the gums dependent on the pres- ence of a carious tooth. Finally, while it is quite necessary to take into account personal predisposition, and still more to admit the influence of a general predisposing cause (the nature of which is unknown though its ex- istence is universally admitted by all physicians), a determining cause is also required for the production of erysipelas. This determining cause plays an essential, and not a secondary part, in the development of the disease. If we grant that under certain circumstances, under epidemic influences, erysipelas is developed independently of traumatic causes, and quite spon- taneously, it must also be admitted, that there are others in which it may at first be supposed that the determining cause is absent, but in which it is afterwards discovered. You no doubt recollect a woman admitted into the clinical wards for erysipelas of the face and hairy scalp, in whom there seemed no proof of the disease having had a lesion of the integuments as its starting-point. Upon her admission, I carefully questioned her, when she denied having had any previous affection which could account for the attack : she affirmed that she had had no sore place on the ears, eyes, nose, or throat, and no breach of continuity of any description on the face or head. Here, then, seemed a case in which erysipelas had come of itself; but subsequently, upon resuming my interrogations, the patient mentioned that she had had violent pain in the ear, which for some time had affected her hearing, or, to use her own expression, had made her hard of hearing. She then recol- lected that along with the pain in the ear and deafness, she had had at the same time an affection of the glands of the neck, that two days afterwards there appeared behind the left ear a red, smarting patch which successively took possession of the face and hairy scalp; and the presence of which we noticed at the time of her admission. Going back thus to the starting- point, we have been enabled to follow the course of the affection of the skin, and again to prove that a case which might have passed with many physi- cians as belonging to the class of erysipelatous cases reputed medical, bore a great analogy, in respect of its starting-point, to what is called surgical or traumatic erysipelas. There ends, however, the analogy; for that which we call traumatic in- fluence [traumatism#] in speaking of erysipelases a something which imparts to that disease a formidable character altogether special. The truth of this proposition is demonstrated by what is seen after wounds of the face, and still more after wounds of the hairy scalp. The appearance of cerebral symptoms is looked upon as a usual and unfavorable occurrence in erysipe- las of the head, while in reality such symptoms are not generally met with except in erysipelas of traumatic origin-using the term traumatic in its strictly accurate acceptation. This probably depends upon recently de- nuded vessels becoming the seat of violent inflammation and producing much greater disturbance of the economy than results from erysipelas deter- mined by a small and partially cicatrized excoriation, or a herpetic ulceration of the nose, ears, or eyes. From this point of view, but only from this point of view, it is necessary to establish a distinction between surgical erysipelas which is often, and medical erysipelas which is seldom, fatal. It is of the latter that I have now to speak. Medical is the name given to the erysipelas which proceeds from an in- ternal cause. One reason why physicians give it this descriptive name arises from the circumstance that in numerous cases, the appearance of the cutaneous inflammation is preceded by fever, general discomfort, and dis- ERYSIPELAS. 199 order of the digestive function, indicating the impress of a pathological modality upon the economy. Considering erysipelas, then, as an eruptive fever, it has, following the example of Borsieri, been placed in the same nosological category as small-pox, scarlatina, measles, and all the exan- themata. That, in my opinion, gentlemen, is a mistake. I do not deny that in some cases the fever precedes the inflammation, but this is a rare occur- rence, the rule being that the local inflammation precedes the general febrile excitement. It is not sufficiently observed that precisely the same phenomena occur in erysipelas of the face as in erysipelas of other parts of the body, whether the cause be external or internal. A person, for exam- ple, has a wound on the foot or leg which becomes inflamed and very pain- ful, the lymphatic vessels and glands connected with it swell, and fever sets in, but some days elapse before the erysipelas appears around the wound. In this case, the fever cannot be looked on as similar to the pro- dromic fever of the exanthematous fevers: its existence is perfectly explained by the inflammation of the wound and lymphatics. The inflammation of the lymphatic vessels, or at least of the glands, precedes the appearance of the erysipelas: this is undeniable. Even Borsieri, while he called erysipelas an eruptive fever, stated that glandular engorgement was a symptom of the beginning of the attack: in the paragraph which he devotes to erysipelas he says: "Illud etiam memoria probe tenendum est quod crebis ex obser- vationibus constitit, si erysipelas artubus inferioribus incubiturum sit, in- guinis et femoris glandulas conglobatas, vasis cruralibus additas, antequam se exerat, leviter dolere atque intumescere consuevisse, axil lares vero ac cervicales, si brachiis aid superioribus loris imminent." Chomel, too, with whose views regarding erysipelas you are acquainted, mentions that painful swelling of the lymphatic glands in the neighborhood of the seat of the disease is one of its most remarkable and constant phenomena. On the other hand, gentlemen, we must not exaggerate the importance of this fact, and say with Blandin that erysipelas is nothing more than lymphitis. Velpeau has conclusively shown that lymphitis and erysipelas are very different affections ; but the renowned surgeon of La Charite has in his turn fallen into the opposite extreme, in maintaining that adenitis is consecutive to erysipelatous inflammation of the integuments. Resting my opinion on my own personal experience, and on the authority of such ob- servers as Chomel, I hold, that almost always the glandular engorgement precedes the outbreak of the erysipelatous inflammation, and also that it is dependent upon a local lesion in the situation of the lymphatic vessels communicating with the swollen glands. Like the woman of whom I have just spoken, patients will tell you that they have had, for example, an ex- coriation of the ear, or that there was something the matter with the ear: they will also complain that the movements of the neck are accomplished with difficulty and occasion pain. There is, therefore, I hold, an inflam- matory action anterior to any characteristic manifestation of erysipelas; and this action is quite sufficient to produce the general symptoms. Finally, the prodromic fever of erysipelas, if this name be allowed, is a symptomatic fever [uneficvre avec matiere]-. it is a fever symptomatic of the inflammation propagated in the lymphatics communicating with the local lesion. This fever continues for one, two, or three days: the erysipe- las then appears, and forthwith proceeds to the different parts of the face and hairy scalp, remaining stationary in one place for three or four days, and fading in the rear of its progress as it advances to another point. It advances rather slowly, taking eight or nine days, or sometimes more, to complete its circuit of the head. In a few exceptional cases, when it has 200 ERYSIPELAS. gone once round the head, it makes a second circuit, starting generally from the place first affected. This repetition of the course is less frequently seen in erysipelas of the face than in that of other parts of the body. The great severity of the general symptoms is a remarkable feature of erysipelas. There are few diseases in which the fever is so high, and the gastric symptoms so urgent. By some the gastric symptoms are regarded as the cause of the erysipelas, but I believe that the very opposite of that proposition is the truth, or in other words, I hold that the gastric disturb- ance is dependent upon the inflammation of the skin. I have often re- called to your recollection experiments of M. Cl. Bernard, which show that when fever is excited in an animal, the normal gastric and intestinal secre- tions are arrested. These results are often confirmed by what we see in medical practice; and in my opinion, the disturbance of the digestive func- tions, generally met with in erysipelas, is obviously the consequence of the fever. Delirium occurs in erysipelas of the face, independent of these gastric symptoms. It is, at least in its aspect, a formidable symptom. There are very few cases which do not present cerebral symptoms when the erysipela- tous inflammation reaches the hairy scalp. The patient occupying bed No. 8 of the St. Bernard Ward has been delirious for two days, and his delirium will probably still continue for two or three nycthemera : it is not likely to cease till the erysipelas has in succession invaded and abandoned the different parts of the skin of the head. Notwithstanding their appar- ently serious character, the nervous symptoms do not alarm me : experience has taught me that what is called medical erysipelas, provided it be not complicated with any other disease, is not a dangerous malady. The prog- nosis, however, is altogether different when it supervenes at the close of an acute disease, at the close of an attack of small-pox, scarlatina, dothien- teria, diphtheria, &c., or during the course of a chronic malady such as phthisis, when it meets with a state of profound cachexia of the system. Erratic erysipelas [erysipele ambulant] is also a more serious affection than erysipelas limited to the head: it jumps from one place to another, and ranges over the trunk and every part of the body. The greater danger of this form of the disease does not arise from the symptoms being more severe than when the erysipelatous inflammation is confined to the face; for generally the fever is more moderate, and the occurrence of delirium is not so frequent. The greater danger consists in the disease being pro- longed for one or two months, and so exhausting the patient's strength ; unless, indeed, the physician, regardless of the high fever, prescribe nutri- tious diet with a high hand, there being no other means by which the destruction of the vital powers can be prevented. But there are some cases in which certain symptoms supervene not sufficiently noticed by our classical authorities: I allude to the extension of the erysipelas to the raucous membranes of the mouth, bronchial tubes, and alimentary canal. In the course of my lectures, I shall, as I have already said, require to return to this important subject. It is unnecessary to tell you that in such extensions of the disease as I have just mentioned erratic erysipelas is diffi- cult to conquer. Dr. Peter gives cases in which it passed from the face to the pharynx, and then to the respiratory passages: once established there, in obedience to the tendency of erysipelas to extend, it propagates itself by degrees in such a way as first to produce simple bronchitis, then capillary bronchitis, then broncho-pneumonia, and last of all death.* * Peter: Article "Angines," in the Dictionnaire Encyclop&dique des Sciences Medicates. T. iv, p. 720. ERYSIPELAS. 201 It has been alleged that when erysipelas begins in the nose and then appears on both sides of the face, it will not extend to the hairy scalp. I have seen cases which might be quoted in support of this opinion ; but I have also seen others in which the erysipelas began in the nose, proceeded to both sides of the face, took possession of the hairy scalp, and made the circuit of the head. Sometimes the danger of a case of erysipelas is in the essential nature of the disease. There are, for example, cases proceeding from contagion which often terminate fatally, and from their very commencement awake the fears of the physician. There is reason to believe that in these cases erysipelas is only the external manifestation of a primary general affection of formidable character; or it may behave like diphtheria, which, in the first instance local, soon poisons the whole system. At the beginning of 1861, one of my colleagues mentioned to me that several persons living in the same house were suffering from erysipelas, which in some had com- menced in the pharynx, and in others at the inner angle of the eyes or external opening of the nostrils. The individual who was first attacked died: the nurse who waited on him died soon after of the same disease; also, several members of the family, and the doorkeeper-who had had occasion to come in contact with the deceased-experienced serious attacks. In July of the same year, 1861, the Gazette des Hopitaux published an additional proof of the formidable character of contagious erysipelas, in the history of the death of two of our young hospital pupils, MM. Gaston Reynier and Ernest Gruteau, who were carried off' by this disease, con- tracted in the wards of M. Nelaton and M. Voillemier. Mrs. Reynier, the mother of one of these unfortunate young men, died a few days after her son, from erysipelas caught in her attendance upon him. Some months after these events, I was called in by my honorable friend Dr. Paris, to consult with him in the case of M. E., upon whom one of our ablest surgeons, Professor Nelaton, had divided the fraenum, for the pur- pose of facilitating the introduction of lithotriptic instruments. M. E. died from gangrenous erysipelas, of which the starting-point was the trifling incision made by M. Nelaton in the fraenum of the prepuce. On the even- ing before his death, his wife, who had attended upon him with great solicitude, was seized with rigors : next day, she had violent sore throat, and twenty-four hours afterwards, exceedingly severe erysipelas of the face, which carried her off at a time when she seemed to have entered upon con- valescence. The maid of this lady, who had likewise waited assiduously on M. E., took ill along with her mistress. Her attack was specially characterized by violent sore throat, and erysipelas limited to the eyelids. Finally, gentlemen, you remember to have seen, in June, 1862, in bed No. 4 of the St. Bernard Ward, a girl of twenty-three, with moderate erysipelas of the face, which had come on during her attendance on her master when he was suffering from phlegmonous erysipelas of the leg. Spontaneous erysipelas, therefore, though generally a mild disease, is sometimes malignant, fatal, and contagious, as was pointed out by Graves. This malignity may either be inherent in the contagium, or dependent upon a special condition of the recipient. It is traumatic or surgical erysipelas, specially infectious, which is also so exceedingly contagious. Traumatic cases supply us with some mournful series of facts in proof of the contagious character of erysipelas. Dr. Pujos of Bordeaux, in a paper, to which the Academy of Medicine awarded a prize in 1866, has reported illustrations of this remark, which, with your permission, I shall now quote in an abridged form. A sportsman injured his right foot with his gun. The wound, in itself 202 ERYSIPELAS. serious, was rendered more so by consecutive hemorrhage, and became complicated with erysipelas on the fifteenth day. The disease invaded the entire limb, gangrenous patches appeared, and adynamia supervened, which led to death on the twentieth day from the accident. The brother, a healthy young man, who had ministered to deceased during his fatal ill- ness, was seized, without any local cause, with spontaneous erysipelas of the face, which extended to the hairy scalp, and became complicated with adynamic symptoms. He died on the eighth day. The sportsman's daugh- ter, a child of three years of age, had a slight burn on the hand which became the seat of erysipelas. The disease extended to the arm and chest, the symptoms at .the same time assuming a formidable character: ulti- mately, the extent of the disease became limited, and the child recovered. The family laundress, after washing the linen of the household, was seized with phlegmonous inflammation of the hand, from which she recovered. The sick-nurse had erysipelas of the face and head : she had no ataxic symptoms, and recovered. But this history is not yet complete ! A sister of charity who had been intrusted with the irrigation of the foot of the wounded sportsman, was forced by fatigue to discontinue her duties : she then felt pains in the right arm, which afterwards became very severe, and were accompanied by nausea, vomiting, and prostration. A large phlegmon- ous abscess opened in the arm, and was followed by several others in different parts of the body : there was a profuse discharge of unhealthy pus: sloughs formed : the general symptoms became more and more complicated ; and at last the patient sunk under the most excruciating pain. The religious community to which this sister belonged was in excellent health when she returned to it unwell. Upon her return, however, different adynamic maladies, of a more or less'severe character, showed themselves in a form at least infectious if not contagious. Health was restored to the commu- nity by the sisters evacuating the convent, and going to the country. Prior to this, however, nine sisters who had waited upon, and dressed the abscesses of the deceased, or who had attended upon some of their sick sisters, had severe attacks of illness, from which two of them died. Dr. Pujos also quotes the case of a woman, who died in an adynamic state from spontantous erysipelas of typhoid type. The physician and two sick-nurses who attended upon her died of erysipelas contracted during their attendance; and a female servant in the family took the disease, but recovered after having been in great danger. Dr. S., successor to M. G., also became ill; but his malady was not erysipelas, and he recovered from it by taking hygienical care of himself. Allow me to quote some additional cases which occurred in this sadly instructive epidemic. At the hospital of Bourdeaux, Dr. G. observed a man who was admitted for an affection of the eye, and placed near a pa- tient with phlyctenoid erysipelas; and who forthwith took erysipelas in a rather severe form. The starting-point was in this case a slight excoria- tion of the lip : the disease, which was phlyctenoid, accompanied by intense fever, invaded the face and hairy scalp, and then ceased without endanger- ing life. The father of M. G., also a physician, came to attend on his son. On the third day after his arrival, he was seized with sore throat, which was followed by phlyctenoid erysipelas of the face and hairy scalp, accom- panied by some general symptoms. He recovered. The sister-in-law of M. G., senior, having come to Nantes to see him, fell ill, and passed through a similar illness. She recovered her health, but lost her hair. Another series of contagious cases commenced with a sailor who had erysipelas of the face around a pimple attributed to the bite of an insect. There was in the first instance erythema : erysipelas then declared itself, ERYSIPELAS. 203 which invaded the head, was accompanied by prostration, and speedily ended in death. A woman who had attended on the sailor, and the wo- man's husband, were similarly affected, and both died. The captain of the ship to which the deceased sailor belonged also took erysipelas, but soon got well on going to sea. Erysipelas, as I remarked, is a very dangerous malady, when it is a complication of some other disease, which from its nature, or protracted duration, has already put in hazard the patient's life; when, for example, it occurs in children along with typhoid fever. It is still more dangerous when it supervenes in the course of the adynamic pneumonia of old people, or when it attacks lying-in women and new-born infants. With reference to what I have already said regarding the epidemic in- fluences which prevailed in 1861, when a terrible epidemic of puerperal fever raged in nearly all the asylums for women in childbed, erysipelas of the face, not generally a dangerous disease, often assumed a bad character, and cruelly contradicted our prognosis. It was also observed that the malady was to a certain extent contagious. One of my medical colleagues has called attention to some such cases, and I have also seen cases of the same description. I met in consultation my honorable colleague M. Hig- gins in the case of a young American lady, who in the sixth month of nursing was affected with abscess of the mamma. The abscess was opened by M. Nelaton: some days afterwards, erysipelas appeared in the wound, and then extended over the chest. The husband of this lady, an officer of the United States navy, left his ship in the Mediterranean to spend some days with his wife. When travelling by railway, he got an insignificant excoriation of the leg. In less than two days after his arrival in Paris, erysipelas showed itself around the little wound, which soon became a diffuse abscess; and for nearly three weeks his life was in danger. Excluding exceptional cases, and epidemic influences, erysipelas of the head is not a formidable disease. From 1831 to 1835, a period of four years, during which I acted as the substitute of Professor Recamier in this hospital, I had only one death in fifty-seven cases. The patient who died was admitted with erysipelas of the hairy scalp, complicated with violent delirium : she died two days after admission. An acute disease in which the mortality is less than one in fifty, may certainly be called benignant in its nature; and perhaps you cannot name another which is equally so. For example, compare bronchitis with erysipelas, and you will find-cir- cumstances being the same and the proportion being kept-that the former kills more than the latter. I am more and more confirmed in this convic- tion by the cases which I have collected in my private practice, in the practice of my colleagues, and in the different hospital services which I have conducted during the last twenty-eight years. I have no doubt some- times seen erysipelatous patients die, but I must say that the fatal issue has been much more frequently caused by the treatment than by the disease. The majority of those who died had been subjected to treatment which I look on as most deplorable; and to which I cannot too earnestly call your attention, for the purpose of putting you on your guard against em- ploying it. When a patient suffering from erysipelas is placed under my care, my rule is to abstain from every kind of treatment. I prescribe a lavement for those who are constipated, and if the constipation continue, I give ten or fifteen grammes of castor oil. This is not very active treatment. You may call it homoeopathy if you like! Such, however, has been my plan for twenty-eight years; and, thanks to it, I cannot recollect losing more than three patients from erysipelas during that period. My treatment, 204 ERYSIPELAS. then, of erysipelas of the face is expectant. I keep my patients in bed, for it is above all things important, both in the acute stage and during con- valescence, to prevent them from catching cold, for exposure to cold leads to relapses. I prescribe slightly acidulated diet-drinks : if the bowels are confined I assist nature by giving laxatives; if the vomiting is violent, I combat it by purgatives. But, gentlemen, I give nourishment-I give nourishment even when there is fever-even when there is delirium. So far from prostrating the patient by withdrawing blood, by bleeding him at the arm, or leeching him behind the ear; in place of making it my rule to ad- minister emetics, and give purgatives in repeated doses; instead of placing the patient on very low diet-I remain with folded arms spectator of a contest, from which I know nature will come forth victorious, if I refrain from disturbing her operations. And I again repeat, that of the great number of cases of erysipelas which I have attended, three only have had a fatal termination: the others spontaneously recovered. That is a fact which I ought not to be afraid to proclaim. In erysipelas, as in a certain number of other diseases which pursue a natural course, we physicians re- quire to beware of trying to direct nature when we see the pathological phe- nomena proceeding regularly, for our ill-timed intervention will only dis- turb the natural course of the disease, and injure the sick man who has sought our succor. I think it right to go minutely into these views, because you are entitled to receive from me an explanation of the manner in which 1 act, or rather abstain from acting, in respect of patients suffering from erysipelas. When you have seen recoveries take place in the practice of other hospital physi- cians in cases treated on the heroic plan, by bleeding, purging, administra- tion of emetics, application of blisters, cauterization of the affected parts with nitrate of silver-when you have seen recoveries take place in spite of that treatment, you may have been apt to believe that they were due to it, and that the remedies employed were sovereign and necessary. But before forming an opinion as to the effects of medical treatment in a disease, it is necessary to be acquainted with its natural history. The primary knowl- edge, in fact, which the practitioner ought to acquire is acquaintance with the natural history of diseases. In my practice, you observe, I adopt active measures in certain circumstances, and in others allow matters to take their own course, attentively watching the symptoms, however, and ready, if occa- sion reqire, to employ the therapeutic resources of medicine. To know when to wait is in our art great knowledge; and prudent waiting explains many successes, particularly those which are sometimes obtained by the sect of Hahnemann. The erysipelas which seizes a person in the midst of health-not that which supervenes in the course of another disease-is one of the maladies which spontaneously terminate in recovery. This statement of course does not apply to that erysipelas which is only the expression of a special influ- ence acting on the whole system. For example, during epidemics of puer- peral fever, lying-in women often sink under erysipelas, but they sink from erysipelas under the same influence which causes other patients of the same class to die of peritonitis or pleurisy-or, to express the idea more correctly, of an affection which is merely the expression of a general pathological condition, really the one cause of death. These important questions, gentlemen, I propose to discuss in my clinical course, when an opportunity is afforded of doing so in connection with puerperal fever. Meanwhile, I have a few words to say on the subject of erysipelas in new- born infants. ERYSIPELAS OF NEW-BORN INFANTS. 205 Erysipelas of New-Born Infants.-Affection often Puerperal.-Differs essentially from ordinary Erysipelas.- Generally fatal. In bed No. 21 of our nursery ward there is an infant, three months old, the subject of congenital syphilis, which, very recently, has been attacked by erysipelas. After spreading over the superior extremities, it reached the base of the chest. In this case, therefore, two diseases were combined, both of which generally prove fatal in very early life. But the erysipelas is already gone, and there seems every prospect of the syphilis being cured. Let me call your attention to the special condition which has probably been the cause of this doubly fortunate result-that condition I believe to be age. The erysipelas of new-born infants is justly regarded as a disease almost as certainly fatal as cerebral fever at a more advanced age. This is a fact which all physicians who have had charge of a children's hospital can verify from their own experience, as I can, after having been twelve years attached to the Necker Hospital. I have found that infants who take erysipelas during the first fifteen or twenty days of life almost invariably die, no treatment being of the least use; but that in those who pass that age, particularly when they get beyond the first month of extra-uterine life, and are thus more removed from their state of foetal existence-more individualized- erysipelas loses much of its formidable character. To the child of eighteen months or two years erysipelas is not more serious than to the adult. Upon what then depends the gravity of the disease in newly-born infants? Does it depend solely on their extreme youth and deficiency of vital power? No! Its formidable character in these subjects arises from quite different causes, which I pointed out long ago, and which have been thoroughly explained by Dr. P. Lorain in one of the most remarkable works which have been published on the subject.* Twelve or fifteen years ago I was struck by observing that, during epidemics of puerperal fever at the Ma- ternity Hospital, a great many children were admitted to my nursery wards at the Necker Hospital with purulent ophthalmia, peritonitis, and erysipelas. I at that time applied the term puerperal to all these affections, and in my published lectures stated that all the children in question had the same disease, only that in some it showed itself in forms different from those it assumed in others. I was then of opinion that epidemic puerperal fever presides over the pathology of new-born infants, just as much as it presides over the pathology of recently delivered women. This view hardly trans- pired beyond the class-room of the Necker Hospital: it did slip into the columns of some medical journals, but it did not at that time obtain general publicity. To Dr. P. Lorain the merit is due of having given it full pub- licity, and of having demonstrated categorically the truth of the doctrine of which I had caught a glimpse. To him science owes its right to regard this view as the expression of well-observed facts. To enable you to under- stand this question, upon some parts of which I wish to touch, I require to give you a succinct analysis of the work of Dr. P. Lorain. During the epidemic at the Maternity, where this able and laborious observer was a resident pupil, he collected the information of which the following is a summary. Of 106 still-born infants, 10 were found to have died from peritonitis, and three of the mothers of these ten infants were carried off by puerperal fever after delivery. Of 193 infants born alive, 50 died of the very same affec- * P. Lorain: -These Inaugurale " Sur la Fi&vre Puerperale chez la Femme, le Foetus, et le Nouveau-ne." Paris, 1855. 206 ERYSIPELAS OF NEW-BORN INFANTS. tions which proved fatal to the lying-in women. The most frequent causes of death were peritonitis, numerous abscesses, purulent infection, phleg- monous swellings, erysipelas, gangrene of the limbs, putrid infection, or some other remarkable septic condition. Mother and child often had the same disease, but sometimes its form and seat were, and at other times were not the same in both; for example, a child sometimes died of peritonitis and its mother of purulent infection, or the child of purulent infection and the mother of peritonitis. In 30 cases in which recently born infants died of peritonitis simple, or complicated with erysipelas, meningitis, or numerous abscesses, mother and child were, in ten instances carried off by the same affection. The infants of fifty women who recovered after having had puer- peral symptoms died of peritonitis. From these facts, the details of which I recommend you to read in Dr. Lorain's excellent thesis, the author proves that it is the same epidemic in- fluence which affects mothers and their offspring. The existence of this influence cannot be disputed, when we recollect that new-born infants very seldom die from the lesions I have just named, except during epidemics of puerperal fever. We cannot deny that there is a bond of pathological community between mother and infant, similar to that which unites the tree's trunk with the branch which proceeds from it. This is admitted in respect of other mala- dies, such as syphilis and small-pox. Who is unacquainted with cases of individuals presenting at birth the scars of variolous pustules? There is not a year, I may say there is hardly month, in which I do not point out to you in our wards new-born infants suffering with syphilis engendered by a father or conceived by a mother affected with that disease. In such cases no one denies the existence of the pathological solidarity to which I have referred, and yet it is denied in respect of puerperal fever! In districts where intermittent fevers are endemic, as in Sologne, Bresse, and some parts of Bourbonnais, infants are born with symptoms of marsh cachexia, nothing being wanting to mark this fact, even the hypertrophy of the spleen being found. Without hesitation we admit that these infants when still within their mother's wolnb have been subjected to the influence of marsh mias- mata. It would be easy to multiply similar illustrations; but still there is a disposition to make puerperal fever an exception to the rule; and the opinion so ably maintained by Dr. Lorain has found obstinate opponents. The day will come, however, when the truth which he has demonstrated with so much precision will be generally accepted. Mother and child then are both subject to the same morbific influence. Let us now inquire, whether there is*not a great similarity in the anatomi- cal and physiological conditions of the two organisms which during gesta- tion are one, and which continue to be one, so to speak, for some days after birth. Acquaintance with the physiological, will enable us to understand the pathological analogy. But before proceeding farther, it is indispensa- ble to define what is meant by a new-born child [enfant nouveau-ne\ : and this I do by quoting Dr. Lorain's definition, which is to the following effect: " The infant comes into the world possessed of organs which have ceased to perform, and of other organs which have not as yet performed, their func- tions. It at once, without any transition, passes from one to another kind of life: it has not, like the young of other animals, a period of repose and physical recruiting, during which the changes requisite for the new kind of existence are accomplished. It has been forcibly thrown into a new medium. The very first efforts of the organs hitherto in reserve are effective: at the very first moment after birth it breathes, and each succeeding inspiration is ERYSIPELAS OF NEW-BORN INFANTS. 207 performed in the same manner as the first: the first mouthful of liquid swallowed brings into play the organs of digestion: every organ in fact responds to the appeal made to it by the new life, and proves faithful to the Power which created it. But it is not enough for the new-born infant to come into possession of its reserve organs, to make trial of them, to use them for all their purposes, and to live in completeness the new life: it also requires to get rid of the organs by which alone it once lived, but which have now ceased to be of any use. The period during which the new func- tions are perfected and the old organs disappear is the period of transition or metamorphosis: during it, the umbilical cord separates, and the navel becomes cicatrized: the epidermis cracks and falls off: the hair is renewed : the meconium is expelled: the umbilical artery and umbilical vein are ob- literated ; and the foramen ovale is closed. The ' new-born ' in fact is the creature in whom this progressive work of separation is going on, and the duration of the period in which it is accomplished is not less than a month." Let us now return to the consideration of the anatomical and physiologi- cal conditions of mother and child. In the mother, after the birth of the fcetus, the placenta is detached from, and expelled by, the uterus. It leaves the surface of the uterus to which it was attached denuded of mucous mem- brane-the protecting membrane by which it was previously covered. This denuded surface is not only in contact with the external air reaching it by the vaginal orifice, but also with fluids accumulated within the uterine cavity-first of all with blood, and afterwards with pus necessarily formed while the reparative process is being accomplished in the wound caused by the separation of the placenta. This, like all recent wounds, is an open door for the reception of contagia. It undergoes changes analogous to those which often take place in the hospitals of large towns in the solutions of continuity made by the surgeon's knife, and which are liable to become the starting-point of general poisoning of the system, like a wound made by a lancet charged with virus. We find the very same anatomical conditions in the child. In the new- born infant, at the moment of its abrupt separation from its mother, at the moment when the functions of foetal existence are superseded by those of the new life, we observe that changes take place which may be compared with those which occur in the organism of the mother. The umbilical cord falls off: having ceased to be of any use, when the placenta which joined the child to the mother was detached from the uterus, it withers up to its point of attachment to that sort of muff formed by the skin of the abdomen, the cutaneous muff which will afterwards be the navel. This is the point at which separation takes place, and this separation is the result of a neces- sary inflammatory process. Upon the fall of the cord, the umbilicus be- comes the seat of a reparatory process analogous to that which takes place in the wound of the uterus. The remains of the cord become detached, and as a necessary consequence of this elimination there is slight suppuration, to which Dr. Lorain has very happily given the name of umbilical lochia [lochies ombilicales]. No expression could have been better chosen to ex- press the truth. In the infant, exactly as in the mother, there is a wound : and with Dr. Lorain I say that the umbilicus in the infant is analogous to the uterus in the mother. The umbilicus and the uterus equally present an open way for the en- trance of infection ; so that if both mother and infant are placed under the same epidemic influence, it is not surprising that both should contract the same disease, just as happens to hospital patients with open wounds when similarly exposed. And what is it that we see happen to these persons with wounds? Phlebitis, metastatic abscesses, suppurating pleurisy, and ery- 208 ERYSIPELAS OF NEW-BORN INFANTS. sipelas supervene. Analogous affections occur in lying-in women, with this difference, that peritonitis is the most common lesion in them, as might be expected from the direct effect produced by parturition upon the abdomi- nal serous membrane: for a similar though stronger reason, the uterus and its appendages are still more often than the peritoneum the first parts in which the disease declares itself. In newly delivered women it is the wound of the uterus, and in new-born infants it is the wound of the navel which is the starting-point. The pathological analogy is still greater, as I have al- ready said, from the circumstance that the child at birth represents a branch detached from the parent stem, which, for a certain time, seems to live by the life of the tree which produced it: the new-born infant may be com- pared to "a layer" which cannot grow by itself till it has taken root. The new-born infant like the layer is not at first entirely nourished by its own sap-by blood which till some time has elapsed it cannot have made: it is still nourished by its mother's blood, it retains all the aptitudes of the ma- ternal organism, from which it is hardly yet separated; and the diseases which it contracts under the same influences as the mother, will assume the same expression as in her. The erysipelas then of the new-born infant will not be ordinary erysipelas; it will be puerperal erysipelas, and possessed therefore of the exceedingly formidable character which belongs to puerperal affections. This formi- dable character depends less upon the smallness of the vital power of resist- ance possessed by the subject, than upon the essential nature of the disease. You can now, gentlemen, explain to yourselves the recovery of the child of bed 21 in St. Bernard's Ward. It recovered because it had got beyond the first days of extra-uterine existence, because it was three months old, because in fact it had ceased to be a "new-born" infant. Erysipelas occurring during the first fifteen or twenty days of life is inevitably fatal. It generally begins to show itself at the pubes, and not at the umbilicus: it is characterized by a vivid redness of skin, and a hard, shining appearance of the subjacent cellular tissue. The infant at the same time falls into a state of great prostration: it suffers pain, and gives expression to its sufferings by cries : it has scarcely any fever. If the infant be vigorous, and at the time of its seizure in apparently good health, you will probably regard the affection as of little consequence. What risk is there in an erysipelas extending over not more than three or four cen- timetres, accompanied by very little febrile excitement and by no disturbance of the functions, the little patient being quite in his usual state of health? In spite of the deceitfully trifling appearance of such a case, you must be pre- pared for its unfavorable termination; for to-morrow, the erysipelas will have extended to the scrotum or vulva, soon, it will have reached the thighs, and invaded the legs, spread over the other side, ascended to the abdomen and trunk, thus advancing, without fading on the parts first affected. At the end of two or three days, high fever will be set up. The infant will become exceedingly restless, get no sleep, and suffer from gastric symptoms, vomit- ing, and diarrhoea. He will cry incessantly from pain. A state of rest- lessness will be succeeded by collapse, which will close the scene on the fifth, sixth, or seventh day. On examining the body after death, pus will be found in the cellular tissue, sometimes suppurative pleurisy, more fre- quently phlebitis of the umbilical vein or of the vena porta, or peritonitis. Adopting the views of Dr. Lorain I have long held that these lesions ought to be looked on as the extension of erysipelatous inflammation from the skin to the bloodvessels and internal parts. Erysipelas, phlebitis, peri- tonitis, &c., are manifestations of one sole disease. In some cases, we see peritonitis in infants, although the erysipelas was on the face and not on ERYSIPELAS OF NEW-BORN INFANTS. 209 the abdomen: and sometimes, on examining bodies after death, we only find indications of the cutaneous inflammation, all the other lesions to which I have directed your attention being absent. Thus you see that the erysipelas of new-born children is an insidious malady. Its formidable character, I cannot too often repeat, depends upon the nature of the cause under the influence of which it is produced, and not on the importance of the local lesion. I cannot sufficiently impress upon you how easy it is to commit serious errors of prognosis. Some of you may recollect a child of twenty-three days old which took erysipelas, when under the vaccine influence, but in the midst of an epidemic of puerperal fever. This infant was born at the Maternity Hospital, when decimated by that scourge: it was removed to the Hotel-Dieu on one of the latter days of March, 1861, along with its mother, who was suffering from abscess of the mamma. You may remem- ber what I said to those who attended my visit: notwithstanding the ap- pearance of vital power in the little patient, though the health seemed excellent, though the cry was vigorous, and the fever moderate, I announced that death would take place within three or four days. I was mistaken : that very night the child died. In point of fact, the disease generally runs a course infinitely more rapid than the strength of the infant and the char- acter of the symptoms lead one to expect. To me it has always appeared a strange fact-but it is one of which I have seen examples-that recoveries from this kind of erysipelas some- times take place when abscesses form in the invaded parts. Within the last two years, I have seen three cases of this kind. I think the only in- terpretation of these recoveries is, that the progress of the disease to other parts is stopped by its exhausting its violence in one locality. In these cases, the affected part becomes much swollen, and the red color of the integuments acquires a deeper shade. Lying-in women attacked by puer- peral symptoms have also a better chance of recovery, when an abscess forms in the broad ligament or iliac fossa. In the beginning of 1861, you saw a child, twenty days old, recover from general erysipelas, after the formation of a deep abscess on the back of the hand. In April of the same year, when an epidemic of puerperal fever, erysipelas, and boils was prevailing in our hospitals, I received into my nursery ward, an infant, twenty-seven days old, suffering from erysipelas. The erysipelas ran over the whole body from head to foot, and even re- invaded the parts which it had occupied and quitted ; and yet for more than twenty days the infant resisted death. It had more than ten abscesses, situated on the feet, ankles, elbows, back, and other parts. It died from acute peritonitis. I freely admit that I have great difficulty in explaining why abscesses, which ought a priori to be serious complications, should on the contrary prove to be a sort of salutary crisis: but the facts are so strik- ing, that however we interpret them, we must at least admit them. Gangrene is another common termination of erysipelas in new-born chil- dren. It arises quickly. Unlike abscesses, it exercises a very unfavorable influence on the whole economy, and in no form of the disease does death take place so quickly as that in which there is gangrene. This gangrene is dependent upon the puerperal state: it attacks infants under conditions precisely similar to those in which it attacks women with sphacelus of the vulva, vagina, uterus, and in fact of all the parts to which parturition im- parts a traumatic condition. Finally, gentlemen, erysipelas in place of running its usual rapid course, may have a long duration; and in lying-in women we sometimes see the puerperal symptoms proceed so slowly as to lead to hopes which are too VOL. I.-14 210 MUMPS. often blasted. Sometimes, also, in new-born infants, the attack is prolonged beyond its usual duration, lasting for ten, fifteen, or even for more than twenty days, as you saw in one of our little patients in the nursery, who died on the twenty-third day. I am not acquainted with any treatment of use in the erysipelas of new- born infants: it is a disease which resists all the efforts of the physician. It is otherwise, however, with the erysipelas of infants who have passed the first month of life. In them, in all respects, it resembles the disease in adults, and all that wre have to take into account is the organization and vital power of the subject. I have often employed a method of treatment in this erysipelas of children, which, in certain cases, has seemed to stop its advance: I refer to the application to the skin, by a hair pencil, of a solu- tion of camphor and tannin in ether. The lotion ought to be applied both to the parts affected, and to the neighboring unaffected parts. You recollect the case of a child, two months old, admitted with its mother to bed 14, St. Bernard's Ward. A day or two after birth, this infant had had a small abscess behind the left ear, which left a slight wound. My attention was called to an erysipelatous redness occupying the angle of the left eye, and invading the eyelid, cheek, and nose. Although there was a little fever, the general condition of the child seemed satisfactory. It took the breast as usual, and digestion was accomplished in a regular manner. I employed the ether lotions containing camphor and tannin. From the first day on which they were used, the erysipelas did not extend beyond the limits it then occupied; and on the fifth day from the date of admission, the infant, having completely recovered, left the hospital with its mother. LECTURE XI. MUMPS. A Specific and Contagious Disease.-Metastases.-Complications. You have seen a young man with mumps [oreillons] in the last bed in the men's ward. I eagerly seize the opportunity of speaking to you about a disease, of which, most probably, we shall not see another case here for a long time to come. This young man, six days before his admission into hospital, felt pains at the angle of the lower jaw, first on one side and then on the other. He at the same time perceived that the cheek and neck were much swollen. He had great difficulty in swallowing, and suffered from headache and fever. However, from the evening of the day on which the patient came under our observation the swelling had sensibly diminished. During the course of the disease, metastasis to the testicles occurred. He left the hospital per- fectly recovered, and without having had any serious symptoms. When I ask students who come up to the Medical Faculty for examina- tion, to tell me what mumps is, many reply that it is an affection of the parotid glands which often supervenes during, or at the decline of severe fevers, scarlatina, measles, small-pox, dothienteria, or puerperal fever; thus, confounding the disease upon which I am now going to address you with parotiditis. That, gentlemen, is a great mistake: parotiditis and mumps, MUMPS. 211 even looking to the anatomical lesion only, are essentially different from one another. Parotiditis is an inflammation of the gland and of its cellular tissue: it supervenes during or after severe fevers, is susceptible of passing, and often does pass, into suppuration. But mumps is, properly speaking, only a simple engorgement [simple fluxion] of the gland. This engorge- ment, as was correctly pointed out by our predecessors, is much more an affection of the interglandular cellular tissue than of the gland itself, and (unlike parotiditis) never terminates in suppuration. Moreover, while parotiditis occurs generally on one side only, both sides are almost invaria- bly affected in mumps, though one is often more affected than the other. Mumps is a specific disease which, for many reasons, may be classed with eruptive fevers; and this I do, in point of fact, following the example of some authors. Like the eruptive fevers, it is a specific malady, and like them, too, it is very contagious. It usually attacks young persons. Some- times, however, it is met with in adults, and even in old people. In such cases, the disease can be traced to contagion: and of this Borsieri gives an illustrative case. Indeed it is only in very exceptional cases, that it is prop- agated otherwise than by contagion. Mumps does not attack the same individual more than once-a fact which is an additional point of resem- blance between it and the eruptive fevers. A malady not severe, and of short duration-nee diu, nee gravioribus, aut saltern non periculosis symptomatibus, si recte curentur, stipaptur, brevique et perfecte resolvunhir-the mumps, " les our les" (for so it is still called), is never, except under circumstances which I will point out to you, attended with serious nervous symptoms; and even in these exceptional cases, the life of the patient is seldom in danger. A fact, to which I propose forth- with to call your attention is, that the older the person attacked, so much the more painful is the malady. Mumps, then, is characterized by a fluxionary engorgement [engorgement fluxionnaire] of the parotid glands, and of the salivary glands in general, for the submaxillary and lingual glands are often affected. The malady first makes its existence known by a painful bruised feeling which the pa- tient complains of in the parotid region, and a difficulty in mastication, partly caused by pain, and partly dependent upon the disturbance of the sali- vary secretion, which is sometimes completely in abeyance. Even during con- valescence, some patients are obliged constantly to drink when eating, from there being no insalivation of the food. There is more or less swelling of the affected parts: sometimes the swelling extends to the face, so as completely to disfigure the patient: occasionally, it spreads to the tonsils and intra- guttural cellular tissue, producing difficulty of deglutition. There is little change in the color of the integuments, but it is not unusual for them to be slightly red. Mumps is a painful disease, and is often at its commencement accom- panied by intense fever, but it subsides rapidly; and at the end of seven or eight days, recovery has taken place spontaneously, and without leaving any traces of the passage of the disorder. But cases occur in which it ter- minates by metastasis, the parotid swelling disappearing abruptly, to attack in males the testicles, epididymis, and tunica vaginalis, and in females, the breasts or sometimes the labia. As a general rule, when this metastasis takes place, there is only slight constitutional disturbance excited by the new local inflammation resulting from the morbid poison; but it sometimes happens that delitescence of the parotid engorgement takes place without the disease becoming completely fixed elsewhere, when general symptoms of very unusual character show themselves, alarming relations, disconcert- 212 MUMPS. ing physicians, and causing the latter to adopt treatment which may prove very perilous. Permit me, gentlemen, to relate two cases in point which I have seen. Tn 1832, I attended a man, about thirty-five years of age, suffering from mumps. The symptoms were following their regular course, the pain had diminished, and the swelling in the parotid region was beginning to de- crease. I had seen the patient in the morning, when he seemed quite as well as I had any right to expect; but in the evening I was hurriedly sent for. I found him with a countenance of inexpressible anxiety; with face pale, and pinched ; with pulse small, rapid, and unequal, and the extrem- ities cold. He had neither vomiting nor diarrhoea, nor any appreciable lesion of lungs or heart. I proceeded in accordance with the indications, giving ether and warm aromatic drinks, and moving sinapisms over the surface of the body. Meanwhile, I anxiously waited for the issue of an attack which had set in under such unfavorable auspices. Next morning, to my agreeable surprise, the patient had smart fever, a full pulse, and a moist skin. There was color in the face, and a lively expression of coun- tenance. But there was swelling of the scrotum, and one of the testicles, particularly the epididymis, was swollen and painful; in fact, there were all the characteristic symptoms of the most acute form of swelled testicle. I recalled to my recollection cases reported by Borsieri, and Morton's/eiris testicularis: I (felt reassured. I respected the local manifestation, which had been the means of relieving the economy from a threatening state. A few days sufficed to accomplish the cure of the metastatic complication, and to restore the patient to perfect health. This case made a deep impression upon me, for it occurred when I was young, and at the age when one forgets nothing. I resolved at the time, in the event of a similar case presenting itself to my observation, to place the tw7o together. Twenty years elapsed before this opportunity was afforded me. In 1853,1 was summoned by my honorable friend, Dr. Moynier, to meet him in consultation in the case of a student, seventeen years of age, about whom there was very great anxiety. This young man, when in the midst of apparently good health (according to the statement, at least, of his parents and the principal of his educational institution), was seized with burning fever, extreme frequency of pulse, desponding tendencies, delirium, picking'of the bed-clothes, vomiting, and the involuntary passing of serous stools; the symptoms resembled those of the bad days of the third week of putrid fever, or the onset of those attacks of malignant scarlatina which prove fatal in a few hours. You can understand the dismay of the family and of the physician in presence of these symptoms. Dr. Andral had seen the patient from the commencement of the illness, and like Dr. Moynier had perceived the danger without being able to recognize its cause. Both were of opinion that the primary indication was to sustain the powrers of life; and, con- sequently, opium in small doses, sulphate of quinine in pretty full doses, and slightly cordial drinks, wrere judiciously prescribed. Ou the following morning, when I met my two colleagues, the condition of the patient con- tinued very much the same, but perhaps was not quite so bad.' We were told of a slight complication which had arisen during the night-swelling of the scrotum, and a swollen painful state of one of the testicles. This was the only organic lesion in any respect noteworthy, and it certainly w'as not of a nature to explain the terrible train of symptoms before us. All at once the history of my first patient flashed across me, and I related it to my colleagues. I ventured to give a somewThat less unfavorable prognosis, believing the affection to be metastasis of mumps. It was, however, in- MUMPS. 213 cumbent on me to yield to the precise statement of symptoms laid before me, and the treatment of the preceding evening was, therefore, continued. Next day, there was much less swelling of the testicle and epididymis, the delirium, vomiting, and diarrhoea had ceased; there was still smart fever, but the pulse had more volume, and the skin was moist. In a few days, the young man was restored to his family, and to health. We now questioned him minutely. He told us, that two or three days prior to the beginning of his illness, he had experienced a feeling of gen- eral discomfort, with pain in the throat, and swelling near the ear, and at the angle of the lower jaw ; and that he had caught cold in an excursion to the forest of St. Germain. He stated that the swelling diminished next day, and that it was on the following day that the alarming symptoms appeared. About the date at which this case occurred, mumps were prevailing in a boys' boarding-school to which I was a physician. I informed the prin- cipal that the malady was not of a serious character, but I also stated that metastasis to the testicle was a possible occurrence, so that in the event of any of the elder boys being affected in this way, he might not suspect the cause to be gonorrhoea. Some days afterwards, on visiting the infirmary of this school, I found one of these metastatic cases. Mumps was also at that time prevailing in young ladies' boarding- schools, and I met with cases of metastasis in those institutions. As I have already said, the metastasis- in women is generally to the mammae. It is a remarkable circumstance that no case of metastasis of mumps to the ovaries has been recorded. As these organs are considered the analogues of the testicles, it might be supposed that they were specially the seat of the metas- tatic engorgements of which I am speaking. In some families, there is a peculiar tendency to this metastasis. Dr. Poinset told me that he and his two brothers had violent orchitis after mumps. The two cases, the particulars of which I have now detailed, are exceed- ingly curious, not in respect of the mere metastasis itself, for that is a fact pointed out by all authors, but on account of the symptoms during the accomplishment of the metastasis, before it was established. Many physicians, especially since the doctrine of the localization of dis- ease has taken so sadly important a place in medical education-a place which, thank heaven I it is daily tending to lose-many physicians, I say, have denied metastasis, to the extent at least of holding that the sympto- matic phenomena do not show themselves until the new lesion is developed. The Hippocratic physicians believe that the morbid poison is afloat in the economy, that it comes in contact with all the organic elements, producing a variable amount of general disturbance precisely similar to what is seen during the period of invasion in eruptive fevers, when terrible symptoms occur prior to the existence of any lesion of the solids, ceasing or decreas- ing as the local lesions show themselves. This is a question involving im- portant clinical facts ; and as it is only from such facts that we can derive a useful acquaintance with it, my duty is to bring them under your notice. The kind of metastasis now being considered by us proves the existence of a sympathy between the parotid gland and the genital organs : the ex- istence of this sympathy is matter of common observation, but its manifes- tation in an inverse order-that is to say proceeding from the genitals to the parotid-is a less familiar fact, A case of this kind, however, was observed by Dr. Peter when he was Professor Gerdy's interne. On May 1st, 1855, a woman, twenty-two years of age, was admitted to La Charite Hospital. She had all the signs of violent inflammatory congestion of the 214 MUMPS. right parotid region : there was swelling and pain, but neither redness nor fluctuation. The patient had anorexia and a little fever. The malady had commenced, four days previously, with great difficulty of moving the lower jaw: an hour after this symptom was experienced, swelling super- vened, and this was followed by pain. But the point of interest in this case was the statement of the patient, that many times before she had had a similar affection, always, however, at the menstrual periods, and in sub- stitution for the menstrual discharge. Her menstruation was irregular, and several times, for months in succession, she had been without her courses : she then suffered from headache, and swelling in the parotid re- gion (generally on the left side), which was sometimes attended with loss of consciousness for an hour. On each occasion recovery took place quickly, after the application of leeches and cataplasms. That is not all: the patient stated that even more frequently than the affection of the paro- tid glands, and always at menstrual periods, when the discharge was scanty, she had had a sort of thrombus of the left nympha, accompanied by acute pain and inability to walk. The symptoms continued for four or five days, and then terminated in slight hemorrhage from the nympha. The patient left the hospital on the 5th May, and was readmitted to the same wards on the 1st September, at a date which exactly corresponded with her catame- nial period. On this occasion, there was again the same inflammatory engorgement on the left side. She stated that in June she had had paro- tiditis; in July, a thrombus occupying the left labium and nympha, fol- lowed by considerable hemorrhage; in August, parotiditis; and in Sep- tember, she returned to the hospital with a repetition of the latter affection. Finally, on the 2d November, Dr. Peter saw her in the out-patient's room, with true thrombus of the left labium and nympha. She did not then wish to come in to the hospital. Gentlemen, it is difficult not to see in this case the reciprocity of classical facts. Just as metastasis to the genital organs may take place in mumps, so was there, in Dr. Peter's case, a metastasis to the parotid glands of an abortive catamenial congestion. Mark well, that in quoting this interesting case, I have not been discuss- ing mumps: in this case the affection was parotiditis, or at least inflamma- tory congestion of the parotid gland. But mumps, as I have told you, is a specific affection, analogous to the eruptive fevers, like them contagious, and like them not attacking the same subjects more than once. I have therefore quoted Dr. Peter's case only as an additional and curious example of a kind of sympathy which is still unexplained. URTICARIA. 215 LECTURE XII. URTICARIA.* A Distinct Nosological Species.-Sudoral Nettlerash [V eruption ortiee sudorale] is no more Urticaria than Morbilliform and Scarlatiniform Sudoral Erup- tions are Measles and Scarlatina.- General Precursory Symptoms.-Ex- citing Causes. Gentlemen : An officer, of about thirty years of age, of good constitu- tion, was seized, in the midst of perfect health, with symptoms which at first presented an alarming character: the symptoms to which I refer were pre- cordial oppression, intense headache, nausea, and high fever. They had set in during the evening, had continued all night, and had scarcely moderated when the physician arrived. At this time the face was considerably swollen, and the swelling occasioned a very disagreeable feeling of tension of the skin; swelling in a less degree was observed over the whole surface of the body. The skin was covered with an eruption characterized by whitish blotches \elevures] surrounded by a slightly red areola. The general symp- toms rapidly disappeared, the patient complained only of insupportable itching, and had completely recovered within thirty-six hours from the commencement of the illness. Some time afterwards he had a return of the same malady, the symptoms being similar to those of the first attack. A similar eruption appeared on the skin, and it disappeared with similar rapidity, possibly under the influence of a mild laxative, which was admin- istered on both occasions. This gentleman could not attribute either attack to any food he had taken. He only recollected that he had eaten a bit of sole on the evening before the first seizure, but he also remembered that it was perfectly fresh; and moreover, till then, he had always eaten with im- punity the various articles which often in others occasion urticaria, such as mussels, various other descriptions of shell-fish, and crabs. Urticaria was the affection from which the officer suffered ; and in the very succinct account I have now given of it, you have recognized the description of the special form of exanthem, the absolute type of which is the eruption caused by the touch of the stinging nettle. I pointed out to you the other day nettlerash [V eruption ortiee~] occurring as a sudoral exanthem, but that eruption does not constitute the malady now under our consideration any more than morbilliform and scarlatiniform sudaminal exanthemata constitute measles and scarlatina. Urticaria, the febris urticata, is a well-defined nosological species, although it originates under the influence of exceedingly various causes. These causes, however, only play a secondary part. They are the exciting causes [causes occasionelles'] waking up according to the idiosyncrasies of individuals a special predisposition, in virtue of which the morbific matter is formed, which is the real, or as the old writers would have called it, the immediate cause of the disease. Urticaria makes its presence known, like the eruptive fevers, by precur- * Fibvre Ortiee: Febris Urticata of Vogel. 216 URTICARIA. sory symptoms, which continue, with variable degrees of intensity, for some hours, a day, or two days. These symptoms are general discomfort, head- ache, horripilation, rigors, precordial oppression, lipothymia, and more or less difficulty in breathing, which is sometimes so great as to excite the fear that the patient will be suffocated. In some cases, nausea and vomiting occur; and there are also some cases in which there are colic, diarrhoea, and all the symptoms of indigestion, but this is when the exciting cause is the eating some particular kind of food. The symptoms are always accom- panied by a well-marked febrile condition. It seems as if the morbific matter were formed in such quantity that the different emunctories are scarcely sufficient to eliminate it, or that before finding its natural exit, which is by the skin, it goes round-pardon the figure-knocking at every door, thus affecting the nervous system, the organs of respiration, and the organs of digestion. The patient soon begins to feel an unusual sensation of heat and itching at particular points in the skin, which forthwith become swollen. This swelling, quite appreciable by the eye, becomes generalized over a more or less extensive surface, occasions a feeling of tension complained of by the patient; and finally, the characteristic eruption appears. The eruption which now occupies the face, and by and by other parts of the body-particularly the shoulders, loins, inner aspect of forearms, thighs, circumference of the knees-consists of blotches which are of a rosy or bright- red, and sometimes dull-white color, always surrounded by a red areola, and exactly resembling in form, extent, and general appearance the erup- tion produced by the stinging of nettles, and sometimes by the stings of bees and wasps: "Forma, magnitudine et specie valde similes Ulis quas urticarum punctura, aut vesparum apumve ictus excitat." The number of the blotches is variable: sometimes they are very few and quite distinct from each other; at other times they cover nearly the whole body, and become confluent. There is nothing determinate in their shape, which may be round, oval, or irregular. When numerous and confluent, they may resemble the eruption of scarlatina; and the rapidity with which they come out, combined with the short duration of the precursory symp- toms, increases the chance of a mistake in diagnosis, if sufficient elements for arriving at a correct opinion are not furnished by the tumefaction of the skin (sometimes great), the pruritus and tingling, and an attentive examination of the blotches. The pruritus and tingling, which give great annoyance to the patient, are increased by the warmth of bed. I have still to call your attention to a circumstance connected with the eruption which was pointed out by Koch, viz., that it may become devel- oped on the inside of the mouth. This observation leads me to ask, whether the chest symptoms of which I have spoken, are not occasioned by an erup- tion or congestive state of the mucous membrane of the bronchial tubes analogous to the eruption and congestion seen on the skin. My opinion is that bronchial eruption may occur in urticaria, precisely as in measles. In the pyrexial exanthemata, the cutaneous manifestations occur in regu- lar order, and follow a definite course, but in urticarious fever [fievre ortiee] this is not the case. The total duration of the disease, including the pro- dromic period, is very variable, ranging between two and seven or eight days; but the individual blotches of eruption disappear very quickly, their duration being from four, five, or six minutes to one, two, or three hours. The eruption, then, does not come out all at once, but in successive crops; and the precursory symptoms which announced the first appearance of erup- tion may recur again and again. Sometimes scratching causes the eruption to reappear in the places scratched. URTICARIA. 217 Urticaria spares neither age nor sex: it attacks old men, adults, and chil- dren ; and women as well as men. A first attack, so far from being pro- tection against a second, is a reason for expecting subsequent attacks, especially in those in whom it supervenes under the influence of exciting causes. In fact, some individuals cannot eat certain descriptions of food without bringing on symptoms of indigestion, or rather of true poisoning, soon accompanied by a more or less considerable urticarious eruption. It is impossible to state in general terms the kinds of food which produce these symptoms, because so much depends upon idiosyncrasy. Shell-fish, particularly muscles, crab, lobster, the ova of certain fish, and some kinds of fish (fresh or smoked) seem to be the articles of diet which are most powerful in exciting urticaria in some persons; whereas in other persons, similar results are caused by dietetic articles of a totally different descrip- tion, such as pork, edible mushrooms, almonds, cucumbers, strawberries, raspberries, honey, &c. Lorry gives cases in which eating rice produced urticarious eruption. A predisposition to urticaria is sometimes hereditary. In October, 1861, I saw in my consulting-room, a lady of fifty, who was very subject to anoma- lous'nervous symptoms, and who had been a martyr to urticaria during the greater part of her life. She had a son and daughter who had inherited from her this distressing infirmity, which was as inveterate in them, as it had proved in their mother. Although urticaria is apparently a simple affection, it assumes in some persons an extraordinarily obstinate character, and becomes a real torment of existence. I have seen it last for years, renewing itself daily, and defy- ing all treatment. Sometimes, also, urticaria has a terrible influence upon the nervous system. I knew a young woman of twenty, who during the invasion-period of an urticarious fever, was seized with nervous symptoms of the most formidable character. She was struck down by profound stupor, paralysis*of the lower extremities, and anaesthesia. In some cases, fortunately very rare, after the eruption has entirely disappeared, nervous symptoms, anaesthesia and amyosthenia, particularly of the lower extremities, continue for a longer or shorter period. The hot weather of summer is often an exciting cause of urticaria; but, as has been remarked by J. Franc, it likewise sometimes appears under the influence of cold, and disappears under the influence of heat. Finally, it is also sometimes absolutely impossible to assign any cause whatever for the appearance of this disease. I will not speak to you, gentlemen, of chronic urticaria, or of urticaria tuberosa. They are forms of the disease which I have never had an oppor- tunity of observing in the clinical wards; but my colleagues of St. Louis Hospital will show them to you, and make you acquainted with them. I have still a word to add on the subject of treatment. When urticaria occurs without any appreciable exciting cause, it is seldom necessary for art to interfere, as the malady spontaneously terminates in recovery. How- ever, at the beginning of the attack, the administration of mild purgatives is sometimes indicated, with a view to divert a tendency to congestion from the respiratory organs to the intestinal canal. To moderate the symptoms, it is generally sufficient to order tepid baths, and cooling acidulated drinks, such as orangeade and lemonade. But when urticaria is excited by the ingestion of alimentary substances, it is necessary, without loss of time, to induce vomiting. After the action of the emetic, draughts containing ether may be prescribed-for example, a quarter of a tumbler of sugared water, containing from twenty to forty 218 ZONA OR HERPES ZOSTER. drops of sulphuric ether, may be taken every half hour. Ether is also in- dicated, when you wish to subdue spasmodic action. When urticaria assumes a chronic form, it sometimes resists the best devised modes of treatment. Some benefit, however, is obtained from fre- quent emetics, the preparations of quinine in large doses, and arsenical solutions. When urticaria appears as a natural crisis of a chronic affection of the mucous membranes, you must not interfere with it. Some time during the year 1860, I saw, in consultation with my honorable colleague, Alfred Bec- querel, a lady of sixty, who had been attacked in the spring with violent bronchitis. Soon after her seizure, symptoms of extensive vesicular em- physema supervened, accompanied by nocturnal attacks of orthopnoea, and constant dyspnoea. It would be tedious to tell you all the therapeutic means I had recourse to. Suffice it to say, that they had all failed, when, about the end of January, 1861, a violent coryza led us to dread an exacerbation of her symptoms, but on the contrary, a profuse urticarious eruption having ap- peared over the whole body, they all at once ceased. I felt that under the circumstances, I ought not to interfere with an eruption, which though un- doubtedly very inconvenient and very obstinate is not dangerous. LECTURE XIII. ZONA OR HERPES ZOSTER. Characteristics.-Accompanying Pains.-Inveterate Consecutive Neuralgic Affections. Gentlemen : You recollect a man of 55 years of age, who occupied bed No. 10 in St. Agnes's Ward in April, 1859. Three days prior to admission, this individual was seized with acute pain behind the left ear. On the fol- lowing day. there was a temporary cessation of pain ; but on that day and the following, he perceived an eruption consisting of groups of blebs. These groups increased in number, and when the case came under my notice, occupied the situations which I am now going to describe. The eruption extended from the ear to the front of the chest: it was most abundant on the left shoulder and arm, within the triangle formed by the sterno-cleido-mastoid muscle, the trapezius and clavicle. Over the pectoralis major muscles, about two centimetres below the clavicle, there was a group extending nearly five centimetres. Behind the ear, over the mastoid process, we found the first which appeared; and between it and the other large group, in the space which I have described, there were other smaller groups. Some were also situated on the external aspect of the shoulder, and three on its posterior aspect. These groups were formed by blebs not yet com- pletely developed, and the patient, who complained of their being painful, traced with his finger the course of different branches of the cervical plexus. He had a good appetite, no fever, and, as he expressed it, was in no way out of sorts. On the second day after admission, the eruption was perfectly bullous. The blebs desiccated in succession forty-eight hours afterwards, and the desiccation was complete on the sixth day, consequently, on the ninth day ZONA OR HERPES ZOSTER. 219 from the beginning of the disease. The neuralgic pains became less severe; and on the twenty-second day the patient was quite well, and left the hos- pital. There were only visible some red spots where the blebs had been. Some months afterwards, another case of herpes zoster came under our observation. The patient was a man, thirty-eight years of age, employed as a servant in the wards. He had been aware of the existence,of the affection for two days; but it occasioned no pain, and only some itching. Till the third day, which was the first day on which he had pain, he did not mention his ailments to me. The eruption began to the right of the tenth vertebra and extended from the vertebral column to the sternum: it consisted of four groups of vesicles of about the diameter of a small walnut, resting on a red surface. The pains were sufficiently acute to prevent the patient sleeping; but he had neither fever nor rigors, and complained of only a little general discomfort. On inquiring into the seat of the pain, we were struck by find- ing that it did not exist in the course of the zona, and was not excited even by pressure on the affected parts, though felt above and below them. The pain was acute, and was aggravated by the slightest pressure. On the eighth day, the patches of herpes zoster changed into very painful furuncu- lar tumors; and soon afterwards, we found an engorged lymphatic gland in the intercostal space below them, and also, red lines leading from the erup- tion to the axilla, indicating inflammation of the lymphatics with its start- ing-point in the furuncular tumors. These circumstances explained why the patient experienced pain beyond the seat of the eruption. At the beginning of the year 1863, another man, acting as servant in the wards, was attacked with herpes zoster of the face, which I showed to Dr. Cusco, my honorable colleague in the hospitals. It was situated on the left side of the forehead. The eruption followed with remarkable anatomical regularity all the cutaneous ramifications of the ophthalmic branch of the fifth pair. It was most confluent in the parts where the external frontal branch spreads out into ascending ramifications; it likewise extended to the eyelids, where the divisions of the descending branches are distributed, and became more violent at the point of emergence of the branch of the nasal nerve which is distributed to the integuments of the lobe of the nose. The neuralgic pains were very acute, and continued long after the disap- pearance of the exanthem. There was also ophthalmia, accompanied by pain and photophobia. In 1862, I had previously seen, along with my honorable colleague, Dr. Delpech, a man aged sixty with herpes zoster exactly similar to that now described. The photophobia continued for more than three months, and was associated with iritis. The very remarkable tendency which herpes zoster sometimes has to follow the course of the nerves is fully established by the cases which I have now related to you. You must not suppose, however, that the erup- tion always assumes the form which I have described. If you attentively look at its distribution on the chest in relation to the direction of the ribs, you will be convinced that it does not follow the course of the intercostal nerves. Generally, on the chest, the half girdle formed by the eruption is almost exactly perpendicular to the axis of the body, beginning, for exam- ple, at the seventh dorsal vertebra, and terminating directly opposite, at the sternum ; but the ribs and intercostal nerves are very far from follow- ing a line perpendicular to the axis of the body. Portions of the vertebral column, and the ribs below the fifth rib, slope very much downwards, and form an angle of more than twenty-five degrees with the spine: theoreti- cally, the zona ought to follow the same direction, but it does not do so, as 220 ZONA OR HERPES ZOSTER. you know from cases you have seen in the wards. It is evident, therefore, that it is not an absolute, though a general, rule that the bullous eruption of herpes zoster follows the course of the nerves. When the eruption appears on the legs, it does not encircle them like a bracelet or garter, but extends in the length of the limb. You recollect a man who occupied bed No. 8 of our St. Agnes's Ward, in whom it was situated on the thighs and extended from the groin to the knee. In August, 1862, I saw in my consulting-room a patient in whom the eruption ex- tended from the hollow of the axilla down to the hand, keeping rather to the palmar aspect of the forearm. In the patient of St. Agnes's Ward, the herpetic patches were distributed exactly in the course of the principal divisions of the crural nerve, while in the other patient, it was very difficult to find any relation between their distribution and the course of the branches of the brachial plexus: in both patients, however, there were acute neuralgic ■ pains in the part of the limb occupied by the eruption. Here then, gentlemen, is a singular disease, the specific nature of which no one can tell. The eruption by which it is characterized consists of patches, individually variable in size, of a bright red erythematous color, and having vesicles grouped upon them-or, more correctly, bullae, form- ing sometimes real blisters, more or less numerous and more or less large. These patches, separated from one another by healthy skin, form, when taken collectively, a sort of half girdle, a sort of zone, which has given the name of zona to the disease, and which is nearly always limited to half of the body, whether the eruption occupy the trunk or the face. On the thorax, its usual seat, the zone never passes beyond the middle of the sternum : on the abdomen, it stops at the linea alba, and behind, it never crosses the vertebral column. " Perpetua lege," said De Haen, " ab anteriore parte abdominis nunquam lineam albam, nunquam a postica spinam (maculcP) transcendunt." The chest is the most usual situation of the eruption, but it is also seen on the abdomen, where it encircles the lumbar or iliac region, proceeding thence to the groin, and terminating on the anterior surface of the thigh, sometimes also invading the genital organs. When the zone occupies the thorax, it generally also invades the arm of the same side, pre- senting patches in continuation of the line of the girdle, either inside or outside of it, or both. In the first of our patients, the eruption was situated on the neck, shoulder, and upper part of the chest and back. Sometimes, it remains limited to the first of these regions: sometimes also, it is con- fined to the face; and in exceptional cases, it appears on the hairy scalp. It has been seen to extend within the mouth. Finally, in a still smaller number of cases, the limbs only are invaded. In all cases, however, there is only one side of the body affected. It is also important to recollect, that when herpes zoster affects the extremities, the groups of eruption, whether they follow or not the course of the superficial nerves, are always, as I have already said, disposed longitudinally, and not round the limb. The half girdle is sharply defined at both ends, and has a breadth of several fingers. The groups which compose it are sometimes rather close to each other, and at other times rather distant. The eruption begins by the appearance of the red irregular spots of which I have spoken, and which come out the one after the other, showing themselves in such a way in some cases, at the two extremities of the line, as to indicate that the succession of eruptions is just about to be completed. The patches at the extremities of the line are larger than those which intervene. Cazenave, from whom I have taken my description of the disease, says that " if its progress be atten- tively observed, small elevations will be seen which have from the first the hue of the patch, and which increase in size and rapidly become true vesi- ZONA OR HERPES ZOSTER. 221 cles, quite distinct from one another, very transparent and resembling little pearls in color. The development of the eruption is completed in three or four days. The largest vesicles are seldom larger than a large pea. When the eruption has attained its maximum intensity, the patch which constituted its base presents great redness, which generally extends one or two centime- tres beyond the limits of the vesicular group. Each patch, therefore, has its phases of increase, and patches are developed one after another in the same way, till all constituting the demizone have been formed." Cazenave continues: " At the end of five or six days the vesicles begin to diminish in size, and the liquid which they contain becomes muddy, opaque, and sometimes blackish, as if it were sanguinolent: the vesicles become wrinkled, withered, collapsed, and are soon covered with small, thin, brown crusts, which fall off in a few days. Every group undergoes similar changes, and about the tenth or twelfth day from the beginning of the disease, the eruption has run its course. Nothing then remains except a few red stains, which gradually disappear. Nevertheless it sometimes happens, even in the simplest cases, that in scratching the parts the patient tears the vesicles, causing them to be succeeded by excoriations, and some- times by small ulerations, which often greatly prolong the duration of the malady. This complication generally occurs at the base of the chest." The mode of succession described by Cazenave is more apparent than real. I concur with the statement that the herpetic groups do not all appear on the same day; but, in general, by the third, or at most by the fourth day the eruption is complete. After that period the vesicles enlarge, and unite to form large bullae, which forthwith become filled with transparent serosity around which the skin has a violet-red color, and seems to yield a slightly slate-colored exudation. Between the eighth and eleventh days the bullae become filled with pus, and go on bursting in succession till the fourteenth day, dating from the commencement of the malady. A great many vesicles, however, remain on the road, if I may be allowed the expression, and dis- appear prematurely, or at least without having become filled with pus. Those which have reached the stage of suppuration burst, as I have stated, and the denuded dermis becomes covered with a blackish crust, which comes off between the fifteenth and twentieth days, when the dermis, at first of a purple-red hue, by degrees loses its deep color, until at the end of two, three, or four months, there is nothing visible excepting a white cicatrix similar to that left by a very superficial burn. It is a remarkable fact to which, gentlemen, I bespeak your special at- tention, that generally (though not always, as some have alleged) the eruption is developed in the track of the nervous filaments of which it de- lineates the course: thus, on the thorax, it may follow the course of the in- tercostal nerves, and in our first case, you saw how it delineated, so to speak, the ascending and descending branches of the cervical plexus. This cir- cumstance is more than a mere descriptive detail: this disposition of the eruption is related to another phenomenon, which, independent of the form of the disease, is a precise and definite characteristic of herpes zoster. This characteristic is the local pain, which almost always precedes and accom- panies the eruption, and often continues long after its disappearance. I am not at present speaking of the prodromic symptoms, the slight discomfort and feverishness which, either nearly or altogether, cease when the eruption has completely come out: I refer to the neuralgic pain in the future seat of the zona, the true, acute, pungent neuralgic pain-a sensation of roasting, of burning heat, a symptom from which the disease derived its old names ignis sacer, feu sacre, and feu de Saint-Antoine. These pains accompany the eruption, and I pointed out to you in our first patient, that they exactly 222 ZONA OR HERPES ZOSTER. followed the course of the articular and subacromial branches of the cervi- cal plexus, and were increased by pressure on these parts just as pressure increases the pain of ordinary neuralgia. There are exceptions, gentlemen, to this rule, and the case of our second patient is one of these exceptions. This individual had no prodromic phenomena, and none of the usual neu- ralgic pains. The pains which he did complain of on the third day of the eruption were situated beyond, that is to say above and below the eruption which it circumscribed, and were not neuralgic, but dependent upon inflam- mation of the lymphatic vessels. At thebeginning of March, 1861,1 was sent for in haste to a lady of sixty- three, who, with the exception of some attacks of gout, had generally en- joyed good health. She had excruciating pain in the left lumbar region, which caused her to utter piercing cries, and although she had no vomiting, her gouty constitution led me to suppose that she was suffering from the passing of renal calculi. Next morning, when the pains were a little sub- dued, I observed an herpetic eruption occupying the surface over the place which had been the seat of such exquisite suffering, and I was thereby im- mediately enlightened as to the nature of the malady. In forty hours from the onset of the attack, the eruption was complete, extending from the spine to the linea alba. The persistence of the neuralgic pain after the disappearance of the erup- tion is, particularly in old people, one of the most remarkable character- istics of herpes zoster. The pain, which always possesses the same acute character, which always produces the same intolerable sufferings, often con- tinues, not merely for months, when the marks of the bulke are still on the skin, but may even continue for several years. I knew an old lady who had herpes zoster when seventy years of age, and who after the lapse of fourteen years still experienced most excruciating pains, particularly during the night. I have at present under treatment a lady of sixty who for the last five years has been horribly tormented by the pains which belong to this disease. There is a curious circumstance in the case of this lady, which I have observed in several other cases: the mere contact of her clothes sometimes produces indescribable suffering, although superfi- cially there is a sort of cutaneous insensibility, which continues long after the pains leave her. I am not quite sure that herpes zoster is not sometimes contagious like erysipelas of the face. On the 20th August, 1862, I was sent for by Dr. Brossard to see with him an old Jewish lady living in Rue Montmorency. She was suffering from softening of the brain. Six weeks before our visit she had had very painful zona on one side of the chest. Her son, aged thirty, who waited on her, took the disease at the commencement of his mother's convalescence. Although the prognosis of this disease is not unfavorable, seeing that it does not endanger life, it is unfavorable in one sense, for it leaves many persons, old people at least, martyrs to those intolerable pains which make both patients and physicians despair of a cure. The pain, and its persistence after the disappearance of the eruption, long ago engaged the attention of observers. Lorry in his treatise " De morbis cutaneis," and, about the same time, Geoffrey and Borsieri pointed out and insisted upon this circumstance. It did not escape the notice of Alibert, Rayer,* and many others; and more recently Dr. J. Parrot has * Bayer : Traite Theorique et Pratique des Maladies de la Peau. Paris : 1835, T. i, p. 330. ZONA OR HERPES ZOSTER. 223 ably discussed the subject of zona and of the pain, one of its predominating symptoms, which pain he classes, as I do, along with neuralgic affections.* Dr. Bazin, my distinguished colleague of the St. Louis Hospital, has found it necessary to distinguish two kinds of zona-one arthritic and of the nature of rheumatism, and the other herpetic. Arthritic zona may often originate in moist cold, and in changes of temperature. It occurs most fre- quently in adults, and almost never in old people. The disease when met with in infancy is arthritic in the vast majority of cases. Herpetic zona, on the other hand, is most common in old age. It is often brought on by men- tal emotions, and is accompanied by jaundice in a certain number of cases. Its vesicles are pretty equal in size, and grouped in a regular manner. The bullse which I have described to you are, on the contrary, most frequently met with in the arthritic form. Herpetic zona is often preceded, and is generally accompanied by, neuralgic pains. These pains sometimes de- crease in severity during the eruption, to return as before with the erup- tion : they are then only a secondary symptom. Dr. Bazin says that the neuralgic pains have been known to continue for months and years, to fol- low an intermittent course, and at last to be replaced by other neuralgic pains in situations different from those which were in the first instance the seat of the neuralgia. Finally, herpetic zona generally has as antecedents, hemicrania, dyspepsia, and other herpetic affections. In relation to these doctrines, recollect the persistence of pains following zona in the aged pa- tients of whose cases I have just been speaking. To prevent the vesicles from being torn, the only means which require to be employed during the acute stage are powdering the affected parts with starch, and during the latter days, bathing them. Some have recommended cauterization with the nitrate of silver, but the expected beneficial results have never been obtained from this treatment. For the pains subsequent to the eruption, it is useful to employ frictions with the mixture of bella- donna, or a solution of atropine or of morphia: subcutaneous injections with the same solutions may also be advantageously resorted to. Flying blisters and vapor douches have also been employed. Often, however, every kind of treatment fails; and I know patients, chiefly women, who have for years been tortured by these neuralgic pains. Acquaintance with the na- ture of herpetic zona led Dr. Bazin to adopt a rational method of treat- ment. Fie gave arsenical preparations with success in the obstinate neu- ralgia consecutive to zoster; and so accomplished cures in cases which had resisted narcotics, narcotico-acrids, and cauterization. His method of treat- ment ought to be imitated. * J. Parrot : Union Medicale, Mars, 1856. 224 SUDORAL EXANTHEMATA. LECTURE XIV. SUDORAL EXANTHEMATA. Multiplicity of Forms.- Cutaneous and Mucous Exanthemata.-Physiological Causes.-Antagonism of the Secretions with the Skin and the Intestinal, Respiratory, and Urinary Mucous Membranes.-Exanthemata produced by Medicinal Agents.-Sudoral Exanthemata becoming Purulent in Ly- ing-in Women and others.-Analogies between Sudoral Exanthemata and Exanthemata Produced by a Virus, or Dependent on Diathesis. Gentlemen : During the hot season, you have often observed the spon- taneous development of cutaneous eruptions in a great many patients. These eruptions are concurrent with profuse perspirations, and are most abundant in those parts of the body which are most constantly bathed in sweat. You have observed them most frequently in the children of our nursery ward, that is to say, in children under two years of age. The greater frequency of these affections in very young children arises from the manner in which they are clad-on the swaddles and flannel binders in which they are always enveloped, and by which they are kept in a state of continual sweating. You have been struck by the multiplicity of forms which these efflorescences assume-you have seen them as erythematous, scarlatiniform, and morbilliform patches, as urticaria, or as vesicular, pus- tular, and papular eruptions. You could not fail to be struck with the rapidity of their development, and the generality of their localization; nor could you but be surprised at their short duration, some disappearing with marvellous ease, either spontaneously, or under the influence of very mild treatment. Finally, gentlemen, you have had an opportunity of watching their transformations: you have seen patches quickly succeeded by vesicles, pustules, or papules, and have often observed a combination of these different forms of eruption in the same patient. Although the study of these affections is apparently of small importance, it really possesses a much higher practical interest than is generally sup- posed. I hope to be-able to prove this to you when I come to speak of symptoms met with in the great pulmonary and digestive organs, and which are somewhat analogous to the appearance of those cutaneous efflor- escences upon the internal skin-the mucous membrane. We will, there- fore, study the relations which may exist between the sudoral eruptionsand the affections of the mucous membranes to which 1 alluded. The number and variety of sudoral eruptions associated together in the same individual, and their transmutations, even when produced by the same cause, is an important fact. My friend Dr. Duclos, of Tours, in his excellent work on sudoral eruptions (published when he was my interne at the Necker Hospital), shows most conclusively, though in opposition to the views of many dermatologists, that it is impossible to establish distinction of species upon anatomical characters alone, as these characters differ according to the epoch at which they are studied, merge into one another, and do not retain specific characteristics throughout their duration. To enable you to understand the subject now under discussion, it will be SUDORAL EXANTHEMATA. 225 indispensable, as we proceed, that I recall to your recollection some points connected with the physiology of the skin. The cutaneous system is en- dowed with excreting and secreting functions. It excretes a certain amount of gaseous matter-carbonic acid gas, hydrogen, and nitrogen: it excretes liquids which it has secreted, the sweat containing solid matter, partly in a state of solution, and partly undissolved : finally, by its sebaceous glands, it secretes and excretes fatty products. When these different secretions and excretions take place in a normal manner; when on the one hand, in rela- tion to quantity, evaporation, which is constantly going on, and secretion balance one another; when, on the other hand, in relation to quality, no alteration takes place in the composition of the products, there is no unusual cutaneous manifestation. But if under the influence of a high tempera- ture, or of any other exciting cause, the excretions become more abundant, though unchanged in quality, symptoms of irritation are soon seen. This irritation is partly produced by a precursory increased determination to the cutaneous organs; and also partly by the deposition of an abnormal quan- tity of solid matter on the surface of the skin. These phenomena of irri- tation account for the exanthemata of which I am now speaking. If an individual sweat profusely, even though he is in the plenitude of health, these special sudoral efflorescences will be observed; they will at times be very painful, and may bear the aspect of measles, roseola, urticaria, &c. I say the aspect only, and not the real characters. However great a similitude they may bear to the eruption of measles, they essentially differ from it in respect of the rapidity of development, absence of general pre- cursory symptoms, shortness of duration, and absence of the symptoms which belong to measles. There are cases, however, in which the diagnosis presents some difficulty, as for example, when the eruption supervenes in children attacked with feverish catarrh, the result of a chill. In such a case, it is often impossible to establish the differential diagnosis on the first day: it is necessary to wait, for the surest way to avoid error is to observe attentively the progress and consecutive characteristics of the malady. So is it also with sudoral scarlatiniform eruptions. During an epidemic of scarlatina, which prevailed at Paris, I was called in to a young girl supposed to have the current malady. After a paroxysm of fever, accom- panied by very profuse sweating, induced by the great heat of the weather and confinement to bed, an eruption identical in appearance with that of scarlatina came out over a great extent of the skin. The absence of the specific sore throat, the natural color of the tongue, and the character of the general symptoms, led me to conclude that the exanthem was sudoral. Next day, it had disappeared ; and none of the symptoms which so often complicate scarlatina supervened. These facts, gentlemen, are very sufficient to explain certain alleged second attacks of measles and scarlatina, and also the mildness of some supposed anomalous cases of these eruptive fevers. Excessive perspiration, then, is in itself a cause of sudoral exanthemata. And precisely analogous consequences result from the excess of other secre- tions than those of the skin. Does not a too copious secretion of tears, which are perfectly inoffensive so long as they are secreted in not more than sufficient quantity to lubricate the surface of the eye, irritate the con- junctiva, and produce bright redness of the eyelids and even of the cheeks? Hence you observe, that an exaggeration of the normal secreticyi may lead to symptoms of irritation and inflammation in the mucous, as well as in the cutaneous membrane. Many cases of diarrhoea originate in causes analogous to those which produce sudoral exanthemata on the skin. Gen- tlemen, you are acquainted with that sort of reciprocity which exists VOL. I.-15 226 SUDORAL EXANTHEMATA. between the cutaneous, intestinal, and urinary secretions. You are aware, that inasmuch as they all act on the composition of the blood, from which they ought to remove certain matters useless for the maintenance of life, none of them can undergo any change without disturbing the equilibrium which existed between the secretions in relation to their influence on the blood. Hence it arises, that the diminution or augmentation of one secre- tion necessitates the augmentation or diminution of another: this is termed the antagonism of the secretions. Sometimes individual peculiarities, idio- syncrasies, exist, in virtue of which the elimination of products which ought to be excreted is accomplished by one emunctory rather than by another. Thus, in one person the skin will be, so to speak, more open than in another, and the least increase of the temperature of the atmosphere, the slightest exertion, or a little febrile excitement, will cause profuse perspiration; while another will not be made to perspire by the greatest heat of summer. But in compensation for deficient elimination by the skin, the lattei' will probably pass large quantities of urine, and have frequent stools; for it is essential that elimination take place by some channel. Some individuals are at once seized with diarrhoea on exposure to a rather warm temperature, or on sleeping with an excess of bedclothes. They call in their physician to set them to rights, and he calls the attack acute enteritis: he is right, for the affection really is enteritis, just as the cutaneous exanthem caused by excess of heat is an inflammation of the skin. Both are the results of secretion, and consequently of increased determination to the parts; but the fact is not sufficiently recognized that both are phenomena of the same class. When, therefore, with a view to check excessive perspiration, we recommend the patient to diminish his covering, we augment in place of diminishing the intestinal flow. This effect is equally brought about, whether we give medicines which increase the determination to the intes- tine, or supplement the precautions against cold already taken by the patient. There is also an antagonism between the secretions of the skin and those of the pulmonary mucous membrane; for as you know, gentlemen, abrupt suppression of the normal cutaneous exhalation caused by a chill excites a mucous flux from the lungs, just in the same way that it excites a diar- rhoea. These considerations will enable you to understand how it is that certain bronchial catarrhs are of the same nature as the cutaneous and in- testinal affections of which I have been speaking, whether the determin- ation to the mucous membrane of the respiratory passages be primary from individual predisposition, or whether that determination, after man- ifesting itself in the skin, and ceasing there, from some particular influence, had declared itself in the pulmonary organs. Certain therapeutic indications obviously arise out of the considerations now stated. The production of diaphoresis by the action of appropriate drinks on the interior is sometimes a successful means of treating bronchial and intestinal catarrh, and of removing alarming and unexplainable symp- toms. But even when perspiration is excited for a therapeutic purpose, we may meet with sudoral eruptions. From among the cases which I could adduce in support of this proposition, I select the following communicated to me by Dr. Dumontpallier. A child, of four and a half years old, of a nervous temperament, but who generally enjoyed good health, was seized during the month of August, with- out any appreciable cause, with irregular intermittent diarrhoea. The child did not lose his appetite; but, nevertheless, he grew pale, and went on losing strength, when, two days after a fit of great excitement, the diarrhoea became so severe, that within twenty minutes he had several stools: they were first SUDORAL EXANTHEMATA. 227 yellowish, then serous, and at last choleriform. Neither vomiting nor cramps supervened, but the' patient fell into a state of profound prostration, and, at the same time, the extremities became cold. The eyes were sunken, and the nose pinched: the pulse was small, thready, and very rapid: death was supposed to be impending. Proceeding to the most urgent indication, which was to restore the threatened powers of life, the child was made to take a dessertspoonful of brandy mixed with an equal quantity of infusion of tea. The little patient was restless for a minute or two, and then fell into a calm sleep. During this sleep his face was bathed with a profuse warm sweat, and the pulse rose. During the night a little restlessness was observed, and the child directed his hands to various parts of the body, as if for the pur- pose of scratching himself. About six o'clock in the morning his mother perceived that he was red from head to foot, and the physician, who had not left him, found that the whole surface of the skin was covered with a sheet of strawberry redness, which was more conspicuous on the hands and feet than on any other situation. Rejecting the idea of an eruptive fever, of which the child had had no precursory symptoms, the diagnosis was re- served. The pulse was full, and less rapid. His sleep was tranquil, inter- rupted only by the itching. From the time at which the cutaneous reaction began, he had had no more stools. By noon the danger was averted, and the scarlatiniform eruption had become pale, as well as less general. In its place, on different parts of the body, there were patches of urticaria, two of which, however, only remained till evening. The natural color of the skin was restored, and the diarrhoea was at an end, for he had not had a stool for forty-eight hours. The intestinal functions, however, remained somewhat sluggish for a time, the child being only able to digest meat nearly raw. But in the course of a few days, under the influence of tonics and bitters, health was completely re-established. It happens sometimes, though very seldom, that the symptoms to which I have been directing your attention show themselves simultaneously in the skin and the mucous membranes: thus, in some individuals, violent exer- cise always brings on both sweating and purging. All the emunctories seem in such persons to be scarcely adequate for the depuration of the blood from its superfluity of excrementitious matter. Here we see occurring physiologically the same thing which we have already studied as a patho- logical occurrence in measles. I pointed out to you that the exanthematous determination takes place in measles simultaneously, and from the begin- ning of the attack, in the skin, intestinal canal, and air-passages, as is mani- fested by the cutaneous eruption, the diarrhoea, and the bronchial catarrh. Hitherto, gentlemen, I have spoken only of the effects produced by a change in the quantity of the elimination: I have now to consider the con- sequences of a change in its quality, of the formation of new bodies, various in their nature and origin, as manifested by different affections of the cuta- neous and mucous organs. Although modifications in the quality of the matter eliminated are not always physically and chemically appreciable, they are, even when not thus appreciable, indisputable, as can be analogically shown. In a great number of cases chemical analysis demonstrates in the sweat substances which have been absorbed internally: sometimes their presence is made known by physical signs, as is the case when the sweat exhales the special odor of copaiva in persons who have taken that drug. Now, as in certain cases, these alterations manifestly coincide with the existence of cutaneous affec- tions, are we not entitled to conclude that they also occur in the other cases in which these cutaneous affections occur, although we cannot physically or chemically prove that alterations on which they depend have taken place 228 SUDORAL EXANTHEMATA. in the sweat? In the absence of physical characters, and chemical tests, the point is established by what I may call pathological tests. A person, for example, lives on exciting diet, and under its influence, different exanthematous affections supervene, such as urticarious eruptions, which appear on some individuals after eating some kinds of shell-fish, mus- sels, for instance, and crabs; in others, the same effect is produced by eating pork; and in others, again, by taking a variety of articles of food, the na- ture of which it would be difficult to specify. In point of fact, it is impos- sible to state in general terms, the conditions under which these eruptions take place, idiosyncrasy having beyond doubt the largest share in their production. Although we cannot in these cases demonstrate physically or chemically the modification which the sweat has undergone, it is evident that a modification has taken place, from the fact, that the affections of the skin determined thereby take place, although there is not the slightest in- crease in the quantity of the perspiration. This fact will be made much more palpable by what I am now going to say regarding exanthemata produced by certain therapeutic agents; for in these cases no one will deny that an alteration has taken place in the sweat, although in numerous instances that alteration is appreciable only in its effects. A patient, for example, takes opium to the extent of producing stupefac- tion. We know that under such conditions opium generally produces pro- fuse sweating; and we also know that it is the most powerful and most energetic of all sudorifics. When, carried by the torrent of the circulation, it presents itself to the different emunctories, and particularly to the cuta- neous emunctory, which is specially charged with its elimination, it there causes an irritation, and an eruption is observed on the skin, which may consist of red erythematous patches, pseudo-morbillous spots, vesicles, or true papules, if the action of the medicine have been long continued. Here then is a substance which imparts a peculiar quality to the excreted sweat, and determines a state of inflammation or irritation of the skin, a transient state, it is true, but nevertheless a state very different from that produced by a mere superabundance of natural sweat. This difference is not shown in the form, but in the intensity of the 'exanthem. So much is this par- ticular inflammatory state dependent upon the special modification which the sweat has undergone in its composition, that in some cases we see the opium-exanthemata supervene when there has been no increased perspira- tion. Belladonna given in certain doses also produces eruptions. In the case of this drug, the exanthem is generally scarlatiniform, as it also is when produced by datura stramonium, mandragora, and most of the poisonous solanese. The effects which turpentine, and still more the effects which copaiba produces on the skin, are known to everybody. After continued use, and sometimes from the first day of taking them, the employment of these medi- cines is followed by sweats, the odor of which distinctly proclaims the agent which has produced them. Papular exanthemata result from their employ- ment, and when their use is long continued, vesicular eruptions appear. Similar results sometimes follow the use of cubebs pepper. The eruptions are exceedingly fugitive, and do not in general continue longer than the period during which the perspiration retains the characteristic odor im- parted to them by the drugs. These medicinal exanthemata have been, and are sometimes still, confounded with syphilitic roseola. From a scien- tific point of view, this is a deplorable mistake; and from a practical point of view, the error is even more deplorable, because it leads to the institu- SUDORAL EXANTHEMATA. 229 tion of antisyphilitic treatment, when our therapeutic measures ought to be limited to those required in simple gonorrhoea, devoid of all specific character. This remark applies to the exanthemata which appear after the admin- istration of iodide of potassium-an eruption which assumes an eczematous and then a pustular form, generally consisting of pustules of acne situated chiefly on the shoulders and face. There are persons, as you know, who cannot take even the most moderate doses of this medicine without having these eruptions, and suffering from pains in the throat, coryza, and intol- erable lachrymation. When these pustules occur in the course of anti- syphilitic treatment, they may be supposed to be of a syphilitic character, unless they are very carefully examined. A mistake of this kind at the beginning of the treatment would matter little, but ata later period, it might be serious, by leading to the prolonged use of a medicine which ought to be discontinued. The resemblance which I maintain exists between sudoral cutaneous ex- anthemata and some affections of the mucous membranes is peculiarly well marked in the class of cases I am now speaking of. The coryza, lachry- mation, sore throat, and pustular affections produced by the iodide of po- tassium are all symptoms of the same class. Being all essentially depen- dent upon the action of this medicine, they all rapidly disappear upon its use being discontinued, and they all equally resist every kind of topical treatment so long as it is being taken. These remarks are applicable to the eruptions produced by copaiva. When they supervene, there is an action on the skin of a nature similar to that which the medicine usually excites in the mucous membranes. Co- paiva, turpentine, and all the oleo-resinous bodies, cause a congestive deter- mination to the mucous membranes, which explains their beneficial in- fluence in gonorrhoea, urethritis and bronchial catarrh: the balsams act by inducing a substitution, by exciting a therapeutic congestion which modi- fies the morbid or inflammatory state which we wish to subdue. When this fluxionary condition proceeds too far in the intestinal canal, the result is a kind of diarrhoea which may be regarded as analogous to sweating. Many other substances produce similar effects on the skin and mucous membranes. The substances I have mentioned are those which are most employed in medical practice, and they are also those which most frequently produce sudoral exanthemata. I must not, however, omit to mention a con- cluding illustration. A patient, for example, takes mercury in large doses, and so brings on violent inflammation of the mouth and salivation. These symptoms become so violent that fever is excited, and with it profuse sweat- ing sets in. The blood, changed in its character by the mercury, upon pre- senting itself to the cutaneous emunctories, there produces mercurial eczema, that serious vesicular affection which Alley has described under the name of "hydrargyria." Sudoral exanthemata are observed during the course of a great many dis- eases. The sweat, altered in its composition, acts as an irritant, and the eruptions of which we have been speaking supervene, whether or not there be an increase in the quantity of perspiration. A patient has a large suppurating sore in some part of the body. Ab- sorption of pus takes place-not purulent absorption, nor absorption of pu- trid matter-but that kind of absorption always going on of the fluid part of pus, and of the materials dissolved in it. This exchange of materials between pus and the economy does not seem to exercise any injurious in- fluence upon the system, provided the pus has not undergone any altera- tion. However, in persons with purulent collections, we sometimes observe 230 SUDORAL EXANTHEMATA. a slight febrile excitement recurring at intervals, and followed by a critical sweat, as if the economy was getting rid of some of the matter imbibed from the abscess. It is under these circumstances that we see exanthematous affections, very various in form, but chiefly vesicular, and when the perspi- ration is profuse and long-continued, the eruption consists of pemphigoid bulla?. The squamous form is also sometimes observed. Indeed, it is un- usual for a person to be laid up with protracted suppuration, without the skin becoming the seat of more or less extensive furfuraceous desquamation. There are some people, whose blood, to use the common expression, is poisonous [venimeuz]. Under the dominion of a true suppurative diathesis, the smallest wound, the slightest excoriation becomes the starting-point of interminable suppuration in some people, an ophthalmia or coryza resisting every kind of treatment. In patients of this diathesis-chiefly children- you will often see eruptions, vesicular and pustular generally, supervene even after perspirations which are not very profuse. The miliary fever of lying-in women is nothing more than a sudoral exan- them. The solution of continuity in the surface of the uterus caused by the detachment of the placenta necessarily suppurates during the reparative process, and thus places the woman in the condition of a wounded person, in point of fact, in the condition of the person in whom we were supposing that there was absorption of the constituents of pus. Both in one and the other, when profuse perspiration is induced, when that deplorable custom is adopted of covering the patient with an excess of bedclothes, we see erythematous patches and measly spots in addition to the vesicular eruption which constitutes the miliary affection. Beware, gentlemen, of supposing that these cutaneous eruptions are never serious. As I have just mentioned, Alley has shown that a general eczematous eruption may result from the excessive absorption of mercury, causing a terrible fever, and nervous symptoms which are often followed by speedy death. A similar result too frequently occurs in the miliary fever of lying-in women. Miliary fever is not, as I have already remarked, a specific affec- tion : it is merely a sudoral exanthem. It supervenes, when the woman has been shut up in a hot room, smothered with bedding, and neglected in those matters of cleanliness, more necessary to her after parturition than when in health. The perspiration secreted in unusual quantity, and im- pregnated with morbid elements imbibed from the surface of the intestine and from the mammae, produces an irritation of the skin which assumes serious proportions. Very recently I was sent for by my honorable friend Dr. Patouilletto see a young recently confined lady. Her nurse was an old woman imbued with the prejudices of last century. The lady had been kept without change of linen, soaking in the lochial discharge, and smothered with a mass of blankets for the alleged purpose of promoting the secretion of milk. From the sixth day of her illness, she had a scarlatiniform eruption ; and four days later, she had, over the whole body, a confluent and frightfully violent eczema. Fever kindled in her countenance, delirium supervened; and this poor young lady died a victim to prejudices equally disgusting and dan- gerous. These eruptions are most frequently met with in the disease called puer- peral fever, and in purulent infection, to one of the forms of which puerperal fever has a great resemblance. Diarrhoea and bronchial catarrh, so com- mon in puerperal fever and purulent infection, are produced by the same mechanism as sudoral exanthemata, that is to say, by the irritation carried to the external and internal tegumentary surface through the medium of SUDORAL EXANTHEMATA. 231 the serosity of the pus in process of elimination by the natural emunetories. These symptoms supervene when, from the suspension of the cutaneous secretion, emunction has to be accomplished solely by the mucous mem- branes, or when the congestion arises simultaneously in the skin, respiratory passages, and intestinal canal. The miliary eruption of dothinenteria has perhaps no other origin than sweat altered in composition by the absorption of putrid elements. Let me remind you that vaccinal eruptions [eruptions vaccinates] are like- wise sudoral exanthemata. I refer to eruptions essentially fugitive and very varied in form, and not to the eruptions of accidental vaccinal pus- tules to which I formerly directed your attention. Sudoral exanthemata are also met with in small-pox during the period of desiccation. They generally assume the pustular form, but it is impossi- ble to inoculate small-pox by using the pus contained in these pustules. Perhaps these exanthemata consecutive to small-pox are due to the presence of the elements of pus in the sweat; for variolous patients may be compared to persons under the dominion of the great suppurations to which I formerly referred. The intensity of the fever, the smartness of the reaction in the skin, and the alteration and modification of its secretions explain the production of the miliary eruption in scarlatina. The mechanism by which the eruptive fevers accomplish their manifesta- tions on the skin and mucous membranes has the greatest possible similarity to that which is in operation in the sudoral exanthemata. In both cases, there is a morbific matter in contact with the blood, which matter journey- ing with the blood presents itself to the different emunetories, and produces an irritation in them, the result being an eruption. The pathological lesion is equally produced by morbific principles traversing the emunetories, whether the agent be medicinal, such as opium, belladonna, copaiva, and mercury, or pathological, such as the elements of pus, the putrid elements of dothinenteria, the virus of small-pox, measles, or scarlatina. But in the eruptive fevers, the manifestations are always uniform, spots and patches being always produced by the same cause, whereas in the sudoral exanthem- ata very varied effects proceed from the same cause. In the latter, they are transient, like the cause which produces them: in the former, they are more persistent, for it is essential that, in accordance with a law almost invariable, the elimination of the morbid matter should follow a natural course. The facts are similar in respect of chronic exanthematous affections re- lated to acquired diatheses such as the syphilitic, or to original diatheses such as the herpetic and the scrofulous. But just as in acute diseases, the exanthematous manifestations take place in hours, days, or at most in weeks, so in diathetic diseases they are accomplished more slowly, and con- tinue for a longer time. In syphilis, the cutaneous eruptions appear a month, two months, or even a year and more after the system has been infected. In the herpetic and scrofulous diatheses, they may even not appear till after a lapse of five, ten, twenty, or forty years. So true is this that sometimes it may not be till a late period of life that a person descended from herpetic or scrofulous parents, and bearing a constitutional resem- blance to their organism, as well as to their external forms, shows signs of a diathesis till then silent. The manifestations, according to the diathesis, are always of the same class, whether the action of the morbific principle be on the skin or on the mucous membrane. In respect of syphilis, all admit that this is the case: 232 SUDORAL EXANTHEMATA. in the attacks of coryza, sore throat, and laryngitis which so frequently supervene in the second period of that disease, no one fails to recognize the influence of the venereal virus. It is visible in morbid vascularity, erup- tions, and ulcerations: there are other cases in which if these lesions exist, they escape our means of investigation in the living subject, but the effects which we do see are not, on that account, the less dependent on the same cause. For example, diarrhoea, as I will tell you when I come to speak of certain anomalous effects of constitutional syphilis, sometimes supervenes as one of the earliest symptoms of the disease, being connected with the intes- tinal determination produced by the action of the morbid poison on the mucous membrane of the digestive canal. In respect of the herpetic diathesis, do we not every day see its manifes- tations in the mucous membranes? And, in relation to the transition of the affection from the external to the internal integument, do we not con- stantly see persons under the influence of the herpetic diathesis take in suc- cession eczema of the upper lip or inferior orifice of the nasal fossae, or chronic coryza, leading sooner or later to ozaena? Here, the affection of the Schneiderian membrane is merely a propagation of the eczema, by con- tinuity of tissue, from the external to the internal integument. In other individuals, granular sore throat will supervene, an affection of the nature and possessed of all the inveteracy of herpes, and which, like an herpetic affection, will give way when the diathesis manifests itself elsewhere in the economy. In other cases, the result will be deafness, caused by the exten- sion of the lesion to the Eustachian tube. In coryza and sore throat you can follow, so to speak, step by step the march of the malady: you can see it approach nearer and nearer to the deepseated parts: you can, for in- stance, see an eczema of the labia majora invade the vagina, attack the uterus, and so become the cause of obstinate leucorrhoeal discharges. Her- petic affections of the mucous membranes are sometimes, also, the first mani- festations of the diathesis. At other times, they are consecutive to the disappearance, spontaneous or from treatment, of other affections of a sim- ilar kind occupying a larger or smaller surface of the skin. Manifestations of the herpetic diathesis are not confined to the mucous surfaces of which I have spoken, but are also met with in those of deeper seat, such as the bronchial tubes and digestive canal. How often do we see a herpetic sub- ject, when suddenly cured of a cutaneous affection, become a sufferer in the organs of respiration or digestion-a sufferer from bronchitis, dyspepsia, or intractable diarrhoea! Examples of this throwing inwards of herpes [repercussion des dartres'] as our predecessors called it, cannot seriously be called in question. Let me quote a case in point published by my colleague, Dr. Noel Gueneau de Mussy: "Some time ago," says my scientific friend, "I attended a lady of about sixty years of age, who for a long time had had chronic eczema of the right temple and cheek: she stated that the malady was extending, and she wished at all hazards to be freed from it. For some time, I opposed her entreaties; but at last, yielding, I prescribed depurative drinks, mild pur- gatives once a fortnight, and the application of a mercurial pomade to the seat of the affection. The eczema disappeared: but this was followed by an obstinate diarrhoea setting in, which did not yield till after two or three months of treatment, and then the eczema resumed possession of the parts which it had so long occupied." "It is difficult," adds Dr. Gueneau de Mussy, "not to admit that there was something else here than the mere effect of derivation, and difficult to avoid explaining by the diathetic condition, the intestinal catarrh which SUDORAL EXANTHEMATA. 233 continued with such obstinacy in spite of a regulated diet and rational treatment."* Do you not find, gentlemen, that there is a great resemblance between Dr. Gueneau de Mussy's case and that which takes place in sudoral diar- rhoea? Do you not find in it an example of that law of compensation and supplement, which I pointed out as existing for the two great emunctories, the skin and the mucous membrane of the digestive organs? Other cases might be mentioned, in which dyspepsia, bronchial catarrh, and inflamma- tion of the cervical glands have followed herpetic affections of the skin. I have likewise seen sudoral symptoms occur simultaneously in the skin and mucous membranes: and the diathetic manifestations of syphilis, herpes, and scrofula may occur simultaneously in both integuments. The possibility of these diathetic symptoms affecting internal organs is a fact of the highest importance, as it leads to therapeutic measures of daily application. Sulphurous mineral waters are remarkably efficacious in the treatment of certain bronchial, intestinal, uterine, and vesical catarrhs, de- pending upon the herpetic diathesis, because they exercise a remedial influ- ence upon it. You are going, perhaps, to send your catarrhal patients to Cauterots, Bagneres-de-Luchon, Aix, and Enghien; but before doing so, ascertain whether they ever had herpetic manifestations in their youth, or at any time in the course of their lives. You will then know what you are about. Gentlemen, thoroughly realize the fact, that some catarrrhal affections are simply exanthemata of the mucous membranes. A chronic bronchitis, for example, has come on under the influence of a chill, but the chill was only the exciting cause which determined the direction of a fluxion, in virtue of which the herpetic principle was carried to the mucous membrane of the respiratory passages, just as it is carried in other cases to the vagina and uterus, or, still more frequently, to the skin. All the considerations into which I have now entered lead to practical conclusions. It is important to know whether cutaneous exanthemata pro- ceed from mere excess, or from vitiation of the natural secretion of the skin. How often has the most simple hygienic advice given in virtue of such knowledge enabled a patient to get rid of an affection which must other- wise have become a very obstinate disease. You may thus have it in your power to snatch from death patients suffering from the general eczema so formidable in hydrargyria, or you may save lying-in women by having the courage to remove their superfluous bedclothes, to have them washed several times a day, or even plunged in a bath. Under the influence of these simple means, they will almost immediately lose their sleeplessness, burning heat of skin, and unbearable itching. I cannot sufficiently impress on you the magnitude of the services you may be able to render to your patients, if you thoroughly realize the importance and frequency of sudoral exanthemata; and if with a view to cure them, you have the courage to fight against the deplorable prejudices propagated by physicians of a former century, and which it is your duty to endeavor to eradicate. * Giteneau de Mussy : Traite de 1'Angine Glanduleuse. 234 DOTIIINENTERI A. LECTURE XV. DOTHINENTERIA, OR TYPHOID FEVER. Specific Lesion.-Furuncular Eruption of the Intestine.-Intestinal Perforation.-Peritonitis without Perforation. Gentlemen : A young man of eighteen, who had lived in Paris only for the two previous years, was admitted to St. Agnes's Ward on the 19th February, 1859. He had been ill for eight days. His illness commenced with debility, lassitude, pains in the limbs, repeated rigors, headache, and distressing insomnia. At first, he struggled against these symptoms, but at the end of four days, he was obliged to keep his bed. 1 found him lying on his back, and feverish, with a rapid pulse, and dry hot skin. The tongue was dry, red at the point, and covered with a slight whitish fur. There was gurgling in the right iliac fossa, but no abdominal tympanites. On the 22d February, there was tympanites, and diarrhoea. The fever was great, and accompanied by delirium. Next day, the abdomen was covered with an eruption of rosy lenticular spots. On the 26th and 28th, there was an increase of severity in the symptoms. On the last-mentioned day, the tongue and teeth were fuliginous, the diarrhoea continued, and the stools were passed involuntarily. As there was retention of urine, it became necessary to use the catheter. On the 29th, the delirium was less violent, the fever had subsided, and the tongue was not so dry. On the 30th, the improvement was still more visible: the abdomen felt soft: he was able to pass his water naturally: the skin looked healthy, the pulse had fallen to 92 from 108, which it was in the early days of his attack: and his intellec- tual faculties were clear. Recovery proceeded continuously till the 18th March, when, it being complete, he left the hospital. The entire treatment in this case consisted of lavements of infusion of chamomile, administered twice in the twenty-four hours, on the 28th and 29th February, and on each of these days a draught composed of twenty grammes of balm-water, one gramme of ammonia, and forty grammes of syrup of orange-peel. In accordance with my usual practice in similar cases, I ordered the patient to have every day some spoonfuls of meat soup and beef tea. In the history of this case, gentlemen, you have recognized the disease generally known by the name of typhoid fever, a disease of which it is very unusual for us not to have some cases in our wards. It is one of the mala- dies most commonly met with in practice, and is found in all temperate climates. It is endemic in some places, specially so in the great centres of population, and this is perhaps more particularly the case in Paris, where every family pays a heavy tribute to it, where foreigners, on coming to reside, are soon attacked by it, and where, as an epidemic, it periodically spreads very cruel desolation. As probably there is not one of you who is not brought into contact with this disease at the very threshold of his medical career, I am desirous, without attempting to discuss the whole subject, to enter upon some considerations in connection with the cases which you have seen, calling your attention to certain peculiarities which they presented, and instructing you in what my experience has taught me. DOTIIINENTERI A. 235 You are aware that, at present, under the nanfe typhoid fever, are included all the varieties of the nosological species formerly known as the synochus putris of Cullen, the putrid fever of Stoll, the malignant nervous fever of Huxham, the mucous fever of Rcederer, the bilious fever of Tissot, and the adynamic or ataxo-adynamic fever of others. It is the same disease which MM. Petit and Serres* have called entero-mesenteric fever, and which Bretonneau has described under the name of dothinenteria [dothienenterie], to indicate the special nature of the intestinal affection.which characterizes it-a furuncular eruption on the intestine-from SoOtyv, a pimple, pustule, or furuncle, and the intestine. This name-dothinenteria-is now the prevailing name of typhoid fever. Names are not of much consequence if there is an exact understanding as to the meaning attached to them, for then they cannot give a false notion of the thing named. The term " typhoid " has been substituted for " putrid," "malignant," and "adynamic," but it is a term quite as'faulty as they are. Conveying as they all do the idea of an essential character, of a special symptom, that particular symptom ought-according to the laws of good nomenclature-to be always found in the disease, and never found in any other disease. But this is very far from being the case in respect of the malady now before us. On the one hand, typhoid phenomena, even the phenomena of putridity, malignity and adynamia are often wanting in the fever called " typhoid," " putrid," " malignant," and " adynamic and on the other hand, they are often met with in diseases essentially different from it. The preferable name then is dothinenteria, because the furuncular eruption on the intestine is as constant and special in this disease as the pustular eruption on the skin in small-pox. It is the name I prefer, though I still employ those of "typhoid fever," and "putrid fever," in conformity with universal usage. Dothinenteria is an acute, febrile, and general disease, bearing more than one striking point of resemblance to the eruptive fevers. Chiefly attack- ing young persons, not occurring in general more than once in the same subject, and being undoubtedly contagious, it has three characteristics common to it and the eruptive fevers; and like them, it also has, as a special character, anatomical lesions, consisting in it of an eruption on the skin, and an eruption on the intestine. The former, called the rosy lentic- ular spots [taches rosees lentieulaires], is much less characteristic than the latter, although some have wished to make the cutaneous eruption the stamp of the disease, and to look on the intestinal lesion as only a second- ary and consecutive sign. The rosy spots are often wanting; and, to quote from statistics, I may mention that Chomel, in seventy cases, could not find any trace of eruption in more than sixteen, though it was searched for at all stages of the disease. If it be argued, that the absence in some cases of the eruption on the skin, no more disproves the exanthematous nature of dothinenteria, than variolas sine variolis disproves the exanthematous character of small-pox, I reply, that cases of variolas sine variolis are infinitely more exceptional than cases of typhoid fever without rosy spots. In some localities, as at Paris, the spots are found with sufficient constancy to justify our looking out for them as the most obvious pathognomonic sign, but there are other places in which attentive observers have never been able to see them. They were entirely wanting in different epidemics in Touraine. Far be it from me, however, to dispute the symptomatic value of this eruption in the cases in which it is present. What I say, gentle- * Petit et Serres : Traite de la Fievre Entero-Mesenterique. Paris, 1813. 236 DOTHINENTERIA. men, is, that the cutaneous'eruption of dothinenteria cannot be regarded as the essential character of the disease-that essential, specific character is the intestinal lesion. On the 21st of June last you had an opportunity of seeing the nature of this lesion in the body of a patient examined in your presence. On our opening the intestines you saw the mucous membrane covered with a copious eruption, formed by the glandules agminatcs of Peyer, in a very turgid, but not in an ulcerated state, some of them being in relief, to the extent of the thickness of a silver five franc piece: some of the solitary glands were equally turgid, and the mesenteric glands were enlarged. The patient was admitted to the clinical wards on the 14th of June, and died four days afterwards. We could obtain no information as to the date at which the dothinenteria commenced. Still, the nature of the intestinal lesions, the glands of Peyer being turgid but not ulcerated, informed me that the disease had not lasted more than twelve or fourteen days. The anatomical researches undertaken for the elucidation of this subject by Bretonneau in 1818, and subsequently when I was his pupil at the hos- pital of Tours, have enabled me to study the progress of the changes which take place in the glands of the intestine, and to describe from day to day the changes which they present. I have published the results of my labors, and you will find them in the Archives Generates de Mededne for January, 1826. The characteristic dothinenteric eruption, formed at the expense of the aggregate and solitary glands of Peyer, does not begin to appear till the fourth or fifth day, and sometimes, according to Professors Chomel and Louis (from whose opinion I differ), not till the seventh or eighth day. It is progressively accomplished in two days, all the glands destined to be implicated not becoming simultaneously affected ; but the eruption is com- plete, at the latest, by the seventh day of the disease. The aggregate glands become turgid, and increased both in length and breadth : the solitary glands project into the intestine: at the same time the mesenteric glands, commu- nicating with the aggregate and solitary glands, share with them the patho- logical changes which are going on, and become enlarged. The turgescence of the glands goes on increasing up to the ninth day. On the tenth day one of two things occurs,-resolution begins, or the affec- tion continues and proceeds through all its stages. In the first case the turgescence of the aggregate and solitary glands of Peyer and of the mes- enteric glands begins to decrease, and goes on gradually subsiding up to the fourteenth day, at which date the affected glands are still a little swollen ; but by the end of the third week resolution is complete, excepting that the mesenteric glands do not quite regain their normal condition till a short time later. In the second case some patches of the aggregate glands of Peyer proceed towards resolution, whilst other patches go on increasing in size: the same may be said of the solitary glands, some of which proceed to resolution, and others become more and more affected by the disease. The mesenteric glands, however, have always decreased in size. On the twelfth day the intestinal affection, till then pimply [boutonneuse], becomes to some extent furuncular [furonculeuse]. The diseased glands become prominent, presenting the appearance of red conical granulations [ fongosites], with slight erosions on their summits, which increase in size, till they form on the fourteenth or fifteenth day a core [un bourbillori] of reddish tissue, deeply stained with an ochre hue by the bile, which at this period of the disease is abundant, and has a special tint: the sphacelated tissue is adherent at its base, and is implanted in the centre of an extensive ulceration. On the following day the core is entirely detached, and in its DOTIIINENTERIA. 237 place there is a deep ulceration, at the bottom-of which, generally, is the muscular coat of the intestine. Sometimes five or six ulcerations of this description may be seen on one patch of the aggregate glands of Peyer, giving it an irregular fungous appearance, so as to render it difficult to recognize the existence of the gland which is the seat of this disorganization. All around isolated ulcers occupy the place of the solitary glands, which have been destroyed by the same inflammatory action. The mesenteric glands, in color resembling the lees of wine, are for the most part so soft that when cut into, or pressed between the fingers, they become almost a pulp. After the seventeenth and eighteenth days the edges of the ulcerations are less prominent, the depth of the ulcers has diminished, and the intumes- cence by which they were circumscribed has begun to disappear. By the nineteenth, twentieth, and twenty-first days, the ulcerations have become superficial, and have a tendency to cicatrize. About the twenty-fifth day cicatrization is complete ; but, generally, the cicatrices arc not consolidated till the thirtieth day. Some ulcerations, however, remain for fifteen, twenty, or thirty days longer, particularly in the glands situated at the extremity of the small intestine. Such is the intestinal eruption of dothinenteria, and such are the differ- ent phases through which it passes. The lower portion of the ileum is the situation for which it has a preference; and when the eruption only occu- pies from three to ten inches of the small intestine, the portion occupied is the lower end of the ileum : the nearer the eruption is to the ileo-csecal valve, the more confluent is it. I have never found spots beyond the second portion of the jejunum, ascending towards the duodenum and stom- ach : they become more numerous in the large intestine, the nearer they are to the caecum. Gentlemen, you will always find these intestinal lesions on examining the bodies of persons who have died of typhoid fever, whatever form it may have assumed, whatever may have been the variety or intensity of the symptoms, provided death has taken place after the fifth day, the period at which these lesions begin to appear. In connection with the intestinal lesion, I ought to mention a theory of Virchow. According to this celebrated anatomist, and according to con- temporary histologists, the follicular crypts of the intestine, the Peyerian patches on the one hand and the Malpighian tufts of the spleen on the other, have the same structure and functions as the lymphatic glands: they are formed of a gland-tissue. And as it is looked on as proved that the lymphatic glands produce the white corpuscles, it follows that hypertrophy of the follicular crypts, Peyerian patches, and Malpighian tufts in typhoid fever lead to the superabundant production of white corpuscles, or in other words, to leucocythsemia, at least in the first stage of the disease.* At a later period, the excessive formation of the constitutional elements of lymph and nuclei distend and ultimately destroy the reticulated texture of the glandular tissue. This of course terminates the leucocythannia. This description is substantially nothing more than a statement of facts disclosed by microscopic observation. The solution of the question is not advanced one step. In cholera and other diseases, there is a similar super- abundant production by the Peyerian glands, while the progress of the symptoms and of the anatomical lesions is very different from those of typhoid fever. In this difference resides the essential character of the disease. The symptoms and the lesions are different, because the morbid * Virchow: La Pathologic Cellulaire. [Traduction de Paul Picard ] 238 DOTHINENTERIA. impetus-or whatever else you like to call it-is different. We are obliged, therefore, notwithstanding the microscopical investigations, and even in consequence of them, to inquire into the causes which produce the disease, into the contagion, the epidemic influence, the nature of the symptoms, and the specific characters of dothinenteria, of which the intestinal lesions, as well as the lesions in other parts of the body, are the effects and not the cause. Gentlemen, you perceive by the description which I have given you, that the intestinal eruption proceeds with an order and precision, which can only be compared to what we see in distinct small-pox. As I do not wish to leave an erroneous impression on your minds, it is necessary, however, to state that while the description which I have given applies to the majority of cases, there not unfrequently occur modifications in the form and prog- ress of the intestinal exanthem, which it would be useless to point out here, but which impress on it characters somewhat different from those I have assigned to it. Cases have been adduced in which there was no appreciable alteration of Peyer's glands, but they are as exceptional as cases of small-pox without eruption, and possibly they were cases of the "typhus fever" of the English, or the "typhus exanthematicus" of the Germans. Let me add that there are some formidable diseases which for the first few days by simulating dothinenteria, throw off their guard unobservant and inexperienced physi- cians. You have seen a considerable number of cases in which the general symptoms at first consisted only of a feeling of discomfort, lassitude, pains in the limbs, and a certain amount of uneasiness in the bowels-the tongue, slightly red at the point and edges, covered with a thin whitish fur, was a little swollen, so as to show the marks of the teeth-there was anorexia, with little or no fever, and the pulse sometimes even below the normal fre- quency-the skin was somewhat dry-and there either were no stools, or the bowels were as regular as usual. We sometimes see our patients continue in this condition for from twelve to thirty days, without the symptoms being sufficiently urgent to oblige them to take to bed; but at other times, after this stage has gone on from twelve or fourteen days, formidable symptoms all at once set in, it may be without appreciable cause, or it may be from indigestion caused perhaps by eating quite moderately, and then the dis- ease declares itself by more characteristic symptoms, and with more or less severity. Well, in these cases of mild dothinenteria, to which the term "latent" has been applied, you will have been able to verify the existence of the intestinal eruption quite as well as in cases attended by the most dangerous symptoms. Nevertheless, it must not be supposed that the furuncular eruption is the entire disease, that the disease is nothing more than an inflammatory affection, an enteritis, as is alleged by those who have given it the name of " follicular enteritis nor must we suppose that the general are more under the influence of the local symptoms, when the intestinal lesions are deepest and most extensive. The enteritis which characterizes typhoid fever has at the autopsy a special character, but it is only one of the elements of the disease. As Laennec remarked, the alterations in the intestinal canal which occur in typhoid fever are no more the cause of its general symp- toms, than the variolous, morbillous, and scarlatinous eruptions are the causes respectively of small-pox, measles, and scarlatina. So far, however, from the eruptions being the causes of these diseases, there are some cases (very exceptional I admit) in which they are wanting, and they are al- ways developed after the symptomatic manifestations of the fever. Finally, if in the mild cases, the dothinenteric eruption may consist only of very D0TI1INENTER1 A. 239 distinct spots, cases have been adduced in which (from death occurring suddenly in consequence of a perforation of the bowel) there has been seen an eruption very confluent in character and presenting numerous ulcera- tions ; while, in contrast, there have been found affected only one or two Peyerian patches in other cases in which death occurred about the fifteenth day of very violent attacks of typhoid fever. My opinion may be summed up in a few words : as a general rule, in dothinenteria, contrary to the general rule in other eruptive fevers (particularly in small-pox and scarla- tina), the severity of the general symptoms bears no relation to the intensity of the eruption. The eruption, though it be a local symptom, is not the less deserving of our serious consideration, for it explains the consecutive abdominal pains which continue for weeks and months, after recovery from typhoid fever; and also, because it is very frequently, during the attack, the starting-point of a mortal complication. About the fifteenth or sixteenth day, at the time when the fleshy core separates, an ulceration forms, which, destroying more or less deeply the coats of the intestine, may proceed in a few days to per- foration. During the period of the cicatrization of the ulcers, we must bear in mind the risk of intestinal perforation, which, by producing very acute peritonitis, carries off the patient with frightful rapidity. You will see such occurrences not only in severe typhoid fever, but even in those cases which are so mild as to be difficult of diagnosis. You are acquainted with the symptoms of peritonitis resulting from per- foration. Whether it occur during the progress of the disease, or during convalescence, the individual is suddenly seized with violent pain in the bowels : this pain is increased on pressure, and rapidly extends to the whole abdomen. At the same time, hiccup, nausea, and intractable vomit- ing of green and leek-green matter set in : a pale, collapsed countenance tells of the pain and anxiety which is being endured : there is considerable fever, and the pulse is small and rapid: there is suppression of urine: the skin is covered with a viscid sweat; and the patient sinks within a period more or less brief. On examination after death, we find the lesions met with in cases of very acute peritonitis; and on examining the intestinal canal, we soon find the perforation, which has been the starting-point of the mischief, and which is always situated in one of the ulcerated Peyerian patches. Sometimes there are several perforations; but there are cases in which we cannot discover any, however attentively we look for them : moreover, there are cases in which it is difficult to see the slightly promi- nent patches of Peyer, which present no traces of inflammation or ulcera- tion. These are the cases in which we have to do with spontaneously developed peritonitis, a subject on which my friend Dr. Thirial has communicated an interesting work to the Hospitals' Medical Society.* Here is one of the cases which he gives. A girl of twenty-one had typhoid fever in a mild form. After the malady had gone on for about twenty days, she was entering upon con- valescence, and beginning to take food, when, after strong mental emotion, she was suddenly seized with very alarming symptoms, pains in the bow- els, bilious vomiting, great change in the countenance, depression of pulse, and general prostration. From these symptoms, exceedingly well-informed physicians without hesitation diagnosed peritonitis, the result of intestinal perforation. Twenty leeches were immediately applied to the abdomen. On the following day, there was no improvement in the state of the patient. * Thirial : Numbers 83, 84, and 85, of Union Medicale for 1853. 240 DOTHINENTERIA. It was then resolved to have recourse to narcotics in large doses, thus adopting the practice from which Stokes of Dublin had in similar cases obtained beneficial results. Twenty-five centigrammes of the thebaic ex- tract were prescribed to be taken within twenty-four hours. Complete abstinence from fluids, and absolute immobility were also enjoined. Not- withstanding this treatment, the vomiting continued : the tongue became dry; and there was no improvement in the other symptoms, with the ex- ception of the abdominal pain. From the first day, it was tolerably bear- able, and had nearly ceased by the third day, the patient not feeling it, unless pretty strong pressure was made on the abdomen. The treatment was continued; but in the evening the patient died, that is to say, in sev- enty-two hours from the onset of the alarming symptoms. The autopsy established the existence of peritonitis. The intestines, throughout the greater part of their extent, were covered with a layer of coagulable lymph, which was soft and recent. The cavity of the pelvis contained four or five ounces of a milky fluid of purulent character. The mesentery was in particular covered with pseudo-membranous deposits of very slight consistence, and of variable thickness. Notwithstanding the most diligent search, not the slightest intestinal perforation could be de- tected. The intestinal canal was found to be perfectly healthy, excepting that towards the end of the ileum, particularly at the ileo-caecal valve, there were four or five patches, not prominent, hut presenting a blackish color: these were Peyerian glands which had been diseased, but had reached the period of resolution. In no situation in the intestinal canal could ulcera- tion or erosion be discovered. The other abdominal organs were healthy: the spleen was small and firm : the liver was normal: the posterior part of the lungs was a little gorged. Two similar cases are described in the work of Professor Jenner, of London. Possibly some of the cases of alleged recovery from intestinal perforation are nothing more than cases of this class; but still, gentlemen, the case I am about to narrate, and which you have had an opportunity of observing in the clinical wards, explains the possibility of recovery, and the mechan- ism by which it is accomplished: it also shows how peritonitis without per- foration is produced by what may be called propagation. You recollect a woman who lay in bed No. 31 of St. Bernard's Ward. Three days before admission, she had left the St. Louis Hospital, where she had had a severe attack of dothinenteria, which had lasted six weeks. She was thin and pale, and had a great deal of fever. She complained of pains in the lower part of the abdomen, which were increased on pressure. She had diarrhoea, and was vomiting yellowish bilious matter. There was con- siderable enlargement of the liver and spleen. My diagnosis was-perito- nitis consecutive to typhoid fever; and I thought that she had had a relapse of the fever, from observing some recent rosy spots on the abdomen. Six days after her admission, the symptoms of peritonitis seemed to be subdued, after the administration of minute doses of calomel-five centi- grammes, divided into ten doses, having been given daily. The pains were less severe, and the abdomen had regained its natural softness. But there were very alarming chest symptoms. Respiration was difficult and hurried. On auscultation, we heard, before and behind, on both sides, numerous mu- cous and sibilant rales: they were most abundant in the lower and posterior region of the right side, where they were likewise finer and subcrepitant: in the same situation, there was dulness on percussion. She spoke in a brief and panting manner. There was more fever than on the previous days. DOTIIINENTERI A. 241 On the following day, there was a profuse mucous expectoration which adhered to the vessel, and so.me of which had a slight ochreous tint, show- ing that bronchitis had penetrated to the extreme ramifications of the tubes, and was gaining the pulmonary parenchyma itself. The cough-the stetho- scopic signs-that is to say, the fine mucous and subcrepitant rales-and the dulness at the base, confirmed this diagnosis. Still, as there was neither blowing sound nor crepitant rales, I could not pronounce the word " pneu- monia." In five days, all these symptoms had yielded. Notwithstanding the diarrhoea, I had given the precipitated sulphuret of antimony in daily doses of 50 centigrammes, administered in pills, each containing 10 centi- grammes. A drop of laudanum was ordered to be taken with each pill. The cough and expectoration were less. The normal sound returned to the part in which dulness on percussion had been observed : only the sibilant and coarse mucous rales were audible; and the breathing was easier. The abdominal symptoms however continued without change; and there was only a little diarrhoea, which at last yielded to the subnitrate of bismuth combined with chalk, to the extent of 4 grammes of each given daily, divided into eight doses, till the twelfth day, when continuous delirium set in, along with general puffiness unaccompanied by albuminuria, and an aphthous condition of the mucous membrane of the tongue and mouth. In conse- quence of these new symptoms, I prescribed cinchona, to the extent of a gramme a day, in coffee without milk. The symptoms continued without intermission for four days; and then the patient died, on the fifteenth day from the date of her admission into the IIotel-Dieu. At the autopsy, we found the usual lesions of peritonitis. All the in- testines were glued together by false membranes, which were easily torn. The adhesions formed pouches filled with pus; and there was no trace of any effusion into the abdominal cavity of the contents of the intestine. On the concave surface of the diaphragm, in the small hollow, the parietal peritoneum was red, presenting vascular arborizations and purulent striae. On exposing the intestine, the serous surface of which was covered by purulent matter and vascular arborizations forming red patches, we saw, toward the lower portion of the ileum, spots of a blackish-brown color, around which there irradiated vascular arborizations more conspicuous than elsewhere. The corresponding portion of the peritoneum was thickened, and puckered like the edges of that kind of purse which is shut by pulling running cords; all the folds of the serous membrane converged towards the black spots of which I have spoken. On opening the intestine, we found that these spots corresponded to the ulcerations which had destroyed the mucous and muscular coats of the bowel, and had reached the peritoneal coat, which formed their floor. These ulcerations of Peyer's glands, char- acteristic of dothinenteria, were from eighteen to twenty in number, and were situated in the lowest metre of the small intestine, and the nearer they were to the ileo-caecal valve, the more confluent were they. In that situ- ation, the whole surface was one vast ulcer, deeply excavated, and jagged at the edges. In the last foot of the ileum, in the centre of two large ulcerations, there were perforations with thin blackish edges, and of the size of a twenty centime piece. In the ulceration nearest to the caecum, blackish filaments were floating, the remains of the furuncular core, in the seat of which the perforation had taken place. The explanation of the absence of intestinal matter in the peritoneum is the stopping up of the perforations by the intestinal adhesions, and the manner in which the convolutions were glued together. The whole of the lower portion of the intestinal canal was arborized: VOL. I.-16 242 DOTHINENTERIA. the arborizations were placed closest together where they were nearest to the ulcerated parts. The mesenteric glands were swollen, softened, and reduced to a reddish pulp. The tissue of the spleen and liver, both of which were considerably enlarged, was soft, and broke down under pressure. The lungs were con- gested, but not hepatized. The encephalon presented no appreciable lesion. This case, gentlemen, as I have already said, explains how the reparation of intestinal perforations, as reported by Stokes and Graves, of Dublin, as well as by other physicians, may take place ; and it also points out to us the pathogeny of peritonitis occurring in dothinenteria without perforation. The peritonitis may be the consequence, as in our patient, of ulceration reaching the peritoneal coat of the intestine, which it does not destroy, but in which it excites inflammation. Supposing the ulcerations to be very few in number, and very far apart from one another, the inflammation devel- oped in the corresponding portion of peritoneum may remain within a very limited space, and be devoid of danger; but supposing, either that the ulcerations are numerous and confluent, or that the inflammation of the peritoneum steadily creeps on, as in erysipelas, the peritonitis, becoming general, may destroy the patient. These cases of partial peritonitis, then, explain the possibility of recovery when perforation of the intestine has taken place. Perforation does not occasion death, except by the violent and general peritonitis set up by the passage of the contents of the bowels through the perforation into the cavity of the peritoneum. Now, when adhesions have been formed between the intestinal convolutions consecutively to the inflammation of their serous covering, the passage of the contents of the bowels is prevented, because the ulcerated openings are shut up by the gluing together of the intestines; and we can understand these adhesions continuing sufficiently long to allow cicatrization of the solution of continuity to be accomplished, and the patient to recover. It was by the operation of the mechanical cause which I have now ex- plained that the woman in the case under consideration did not succumb in consequence of the perforation. She died from general peritonitis, pro- duced by the extensive ulceration of the intestine reaching the serous membrane, and not from sudden general peritonitis consecutive to perfor- ation and escape of fecal matter; for, as I pointed out to you at the autopsy, the convolutions of intestine were glued together in such a manner as to prevent that escape. In respect of diagnosis, the symptoms are the same whether the peritonitis be or be not the consequence of perforation. It has certainly been alleged that peritonitis consecutive to perforation may be recognized by the spon- taneousness and excessive acuteness of the pain declaring itself first in the region of the caecum and second portion of the ileum, the situation in which perforations are most common, soon extending to the whole abdomen, and being aggravated by pressure; and it has also been alleged that in peri- tonitis consecutive to perforation, there is always suppression of urine. These signs, however, are of very little use as guides to a differential diag- nosis, which can only be established by an examination of the body after death. Were such a differential diagnosis possible, it would have some impor- tance in respect of prognosis, because peritonitis without perforation is not so serious as peritonitis from perforation, which is almost inevitably fatal. The impossibility of ascertaining during life the nature of this abdominal complication justifies our worst fears as to the issue of a case in which it exists. Finally, gentlemen, you can understand from what I have said, DOTHINENTERIA. 243 that, considering the alterations to which the intestinal canal is liable in dothinenteria, you ought to be reserved in your prognosis in this disease, recollecting that even in cases in which the appreciable signs are indicative of a mild attack, at the very time when your patient seems to be out of dan- ger, and you are going to announce his recovery, you may witness the symptoms of that terrible complication, intestinal perforation, or of peri- tonitis without perforation, a complication which though less formidable, is' very dangerous. Intestinal Hemorrhage.-Hemorrhagic Putrid Fever. A woman, aged 64, was admitted to the Hotel-Dieu on the 7th March, 1859, where you saw her lying in bed No. 31 of St. Bernard's Ward. 1 call your attention to her age, because, as a general rule, dothinenteria only attacks young subjects. This woman died on the seventh day after admission, having been carried off by a complication regarding which I now wish to speak. When she came into our wards, she was delirious, and in a state of great prostration. The bowels were in a sluggish condition: pressure over the iliac fossa did not occasion gurgling, and there was no diarrhoea. The pulse was 108: there was a little dyspnoea, with some subcrepitant rales at the base of the right lung. The spleen was not enlarged. We learned that the illness began with headache and shivering. Next day, I observed spots on the abdomen, possessing some of the char- acters of typhoid spots. Three days latter, their typhoid character was undoubted. On that day, there was marked amelioration of the symptoms. In the evening, my chef de clinique, M. Moynier, saw the patient taking some meat soup with appetite, and complaining that it was insufficient iu quantity: three hours later, abdominal hemorrhage set in so profusely that the blood inundated the bed, and flowed over on the floor of the ward. In less than an hour the patient was dead. At the autopsy, the upper portions of the small intestines were found to be healthy; but in the lower portions, the following lesions were seen. The Peyerian patches were very much affected. At about six or eight cen- timetres from the ileo-csecal valve, one of the patches was ulcerated in such a way as to expose the bare peritoneum: its edges were turgid, and its sur- face was covered with detritus exhaling a fetid odor. A little higher up, there were other patches of about one or two centimetres ulcerated, so as to lay bare the muscular coat of the intestine. The patches were hypertro- phied, and softened. The solitary glands w'ere also in a very diseased con- dition. The intestine contained a large quantity of blood, which had im- parted a reddish-black color to the mucous membrane. There was no fecal matter in the intestinal canal. The mesenteric glands were blended together in an enormous mass of fat. From the lesions now described, it is evident that the disease had reached its fourteenth or fifteenth day. In size, the spleen was natural, but it was of a very soft consistence. The liver had lost its natural consistence, and was hypertrophied. Both lungs were con- gested. The heart was distended with black clots. There was no lesion of the brain. This is the third case which I have seen within seven years of a person dying of intestinal hemorrhage in the course of an attack of dothinenteria. In the two other cases, the patients did not die fromithe immediate conse- quences of the loss of a large quantity of blood, as in the woman whose case I have detailed. One of them was seized on the twenty-third or twenty- fourth day with intestinal hemorrhage, which recurred at intervals during 244 DOTHINENTERIA. three or four consecutive days. Death took place in consequence of these successive hemorrhages, the patient having been reduced to a state of anaemia and profound debility. The other patient, on the nineteenth day of the typhoid fever, had ataxic nervous symptoms, when a moderate attack of hemorrhage supervened, after which a great improvement was observed in the condition of the patient, which continued for eight days. Then, how- ever, the nervous symptoms returned, and she had a second and a third attack of hemorrhage. The nervous symptoms, in place of becoming calmer, as after the first loss of blood, increased in severity and carried off' the patient. Intestinal hemorrhage is a frequent complication of dothinenteria: it is perhaps even more common than is generally believed, judging from the fact, that it is often not till the autopsy that its existence is revealed: in such cases, on opening the intestinal tube, we may find a greater or less quantity of blood, none of which has passed below the ileo-csecal valve. While a somewhat profuse hemorrhage into the bowel might be suspected during life from the general symptoms, such as increased debility and a sudden paleness of the skin, a more moderate loss of blood might escape notice. Generally, the hemorrhage shows itself externally; and, according to the nature of the case, the blood is passed almost pure, in a state which though not pure admits of easy recognition, or in a very altered state: when it has remained long in the intestine, it is a blackish matter resembling tar in appearance. You will read, and you will hear said by everybody, that these hemor- rhages are formidable complications, and increase the danger of the disease. This is the opinion of the most reliable physicians; but nevertheless, when thus expressed, it is far too absolute; and as for myself, I confess, that after holding that opinion for a long time I now profess the opposite doc- trine-, believing that hemorrhages in typhoid fever, so far from possessing the character of danger imputed to them, are usually of favorable augury. Such is also the opinion of Graves. When I read this proposition for the first time in the clinical lectures of the Dublin professor, being still under the dominion of opposite views in which I had been educated, I was amazed that a man of such sterling merit and high repute should disagree with me in a matter which I believed I understood. However, the opinion of so great an authority caused me to reflect, and reviewing the cases which I had seen, I recollected recoveries in cases in which hemorrhages had oc- curred. I, therefore, from that time directed my attention more diligently to the point: and I now say, that while the three cases of which I have just spoken seem to confirm the prevailing idea as to the gravity of intes- tinal hemorrhages in typhoid fever, I can cite as a set-off to them a much greater number in support of the doctrine of Graves. Without going beyond our wards in search of examples, I will recall two cases which occurred under your own observation. A girl aged 20, of good constitution, was admitted to bed No. 5, St. Ber- nard's Ward, on the 14th October, 1857. She had been ill for eight days, but had not been obliged to take to her bed till the fourth day. The doth- inenteria followed its regular course, without presenting any other symp- toms than considerable weakness accompanied by very moderate fever and diarrhoea, till the 18th October, the twelfth day of the attack, when profuse intestinal hemorrhage occurred: she nearly filled a chamber-pot with blood, which was black, fluid, and very fetid. The hemorrhage recurred next day, when the discharged blood was similar to that passed on the first occa- sion ; and on the following day the stools were still black and fetid. The general symptoms were not such as to occasion much alarm; and DOTHINENTERIA. 245 from that time they became sensibly less severe; from day to day the fever abated, and on the 17th November, the patient, having entirely recovered, left the hospital, a month after admission. It was a remarkable circum- stance in this case, that notwithstanding the enormous quantity of blood lost on two occasions, the patient, who naturally had color in her face, did not lose it, and did not seem to be weakened. Last year, a man, aged 27, tall, of good constitution, but having a pale complexion and fair hair, was admitted on the 10th of June, to bed No. 16, St. Agnes's Ward. He had been ill for eleven days with putrid fever, the symptoms of which were well marked and severe. He had lately come to reside at Paris, where he was employed as a day laborer. For a week he had been feeling languid, and complaining of violent headache, when, on the 7th June, he was obliged to keep his bed. The abdominal symptoms preponderated, and were characterized by considerable tympanitic disten- sion, and by profuse and frequent stools. There was high fever, delirium, and a very dry state of the tongue. On the 23d June-the 24th day of the dothinenteria-the patient had during the day three copious motions, consisting of liquid black blood mixed with some clots. Immediately after this hemorrhage I observed a marked improvement. In the evening it was noted that the fever was moderate; that there was no abnormal heat of skin ; that there was an appearance of greater comfort, and a desire for food. The tongue, however, continued foul and sticky, with its centre red and dry. Next day I found that the patient had had three ordinary diarrhoeal stools since the hemorrhage of the previous evening. The tongue was moist, without being red, and at its base there was a thin yellowish-white fur. The pulse, till then above 120, had come down to 80. The patient, however, was suffering from an ecthymatous eruption, yhich from the first week of the fever had been out on the hips, back, and thighs. Over the sacrum the pustules had become converted into large superficial sloughs, not involving the entire thickness of the dermis: their base was of a grayish hue. With a view to get rid of the complications occasioned by the contact of the affected parts with the urine and excrementitious matters, and from the pressure of the dorsal decubitus, which the patient constantly maintained, it occurred to me to make him lie on straw, covered only by a sheet, a practice adopted at the with the gateuses to prevent excoriations of the seat. In accordance with my usual plan, the patient had taken nourishing diet throughout his attack: and now the quantity of broth was increased. The sloughs cicatrized, such of the pustules of ecthyma as'had not ulcerated dried up, and the general condition of the patient was satisfactory, when, on the 26th, a new intestinal hemorrhage supervened, complicated with epistaxis and an efflux of venous blood through the mouth from the nasal fossae. Notwithstanding this new complication, convales- cence was speedily and satisfactorily completed, the patient being soon able to leave the hospital. These cases are conclusive. I could add others, likewise derived from my own practice, as well as others observed by physicians of recognized eminence. Thus Dr. Ragaine, of Mortagne, states that in four hundred cases which he saw, eleven had intestinal hemorrhage, and all the eleven recovered.* Very recently Dr. Juteau of Chartres read, before the Medical Society of Eure-et-Loir, a very interesting paper on an epidemic of dothin- * Ragaine : M6moire sur tine Epidemie de Fievre Typhoide qui regna a Moulins- la-Marche pendant les 1855, 1856. 246 DOTHINENTERIA. enteric fever, in which he stated that five of his patients had had intestinal hemorrhage, and that all of them recovered. I would not wish, however, to be represented as saying that these hemor- rhagic complications, hitherto looked on as always serious, are really quite free from danger. They are in too many cases exceedingly serious. The hemorrhage may by its profusion destroy the patient, just like any other loss of blood; and you have heard of death resulting from intractable epis- taxis. Intestinal hemorrhages are also formidable when, by recurring, they exhaust the patient and cause him to fall into a state of anaemia and debility, leading to extinction of vital power and ataxic nervous symptoms, such as occurred in one of the three cases I mentioned. Finally, intestinal hemor- rhages really are serious complications of typhoid fever, when, occurring along with bleeding from the nose, gums, lungs, urethra, or along with sub- cutaneous hemorrhage, they are symptomatic of a dyscrasia against which the resources of art are powerless. I am now speaking of the hemorrhages which constitute one of the characteristics of the disease to which our pre- decessors gave the name of ''putrid fever" as a distinctive term, and which at present we call "hemorrhagic putrid fever," but in these cases it is not, strictly speaking, the loss of blood which kills: death is the result of the peculiar morbid condition which constitutes putridity. We had very recently, in our St. Bernard Ward, bed No. 5, an example of this hemorrhagic putrid fever. The patient was a woman aged 22. She stated that she had always enjoyed good health, and that she had been confined four months previ- ously. She had been ill for five days, and a short time before her seizure she had menstruated as usual. Her illness began with headache, vertigo, singing in the ears, accompanied by obvious deafness and fever. All these symptoms were present when I first saw the patient. The skin was hot, and the pulse 108. The patient complained of general lassitude, pains in the limbs, particularly in the legs, and rachialgia. She also complained of pain in the throat, but nothing particular was visible there. The tongue was very foul. There was a little cough, accompanied by the expectoration of stringy mucus. The patient complained that she could not sleep, and she had disturbed reveries. When spoken to, however, she answered ques- tions with precision. In connection with the digestive organs, the symp- toms observed were nausea and constipation. I prescribed five centi- grammes of calomel, to be followed in a quarter of an hour by one gramme of the powder of jalap. During the night, there was noisy delirium mingled with speaking and laughing. There wTas no expression of hebetude in the countenance : there was not much fever, and the skin was moderately hot: the tongue was red, and covered at the base with a very thick slimy fur. On drawing the nail lightly across the skin of the forehead, abdomen, and arms, I observed that the " tache cerebrate" was very distinctly produced, and that it remained for some time. I prescribed calomel in small doses, viz., 5 centigrammes divided into ten portions, of which one was to be taken every hour. On the third day after admission, and the eighth of the disease, the delirium was less violent, and the patient answered questions. The tache cerebrate was very obvious, and remained for a long time: the bowels were sluggish : the pulse was 108 : the gums were bleeding. The treatment of the previous evening was continued. Next day, there was still delirium and deafness. The pulse was rapid and very soft. Diarrhoea was still absent. There wrere some rosy lenticular spots on the abdomen. The gums continued to bleed; and on causing the patient to lie on her face, wre saw large ecchymoses on the posterior surface DOTHINENTERIA. 247 of the body, particularly on the trunk and arms: they were also seen on the anterior aspect of the chest, round the left breast. The ecchymotic spots were prominent in their centres. On auscultation, some subcrepitant rales were heard on both sides, and a blowing sound over the right infra-spinous fossa. I ordered four grammes of the powder of cinchona, to be taken in infusion of coffee: also, a mix- ture of four grammes of eau de Rabel, four grammes of syrup of rhatany, and 100 grammes of water-to be taken in doses of a dessertspoonful. For diet-drinks, iced Seltzer water and iced milk were prescribed. The excitement and delirium continued ; and diarrhoea supervened. The ab- domen was not tympanitic. The thoracic complications increased. The breathing was loud; and the blowing sound, still audible in the right infra- spinous fossa, was a 1st) heard at the base of the left lung. I substituted a gramme of sulphate of quinine for the cinchona, the same formula for its administration being adhered to. On the eleventh day of the disease, the woman died. The cerebral symptoms continued till the last. The chest symptoms had increased, the blowing sound being audible from base to apex in both lungs. The dysp- noea had become intense, the inspirations being fifty-six in the minute. The pulse was 136. Blood was flowing from the mouth. The autopsy was made on the following day. We found no trace of hemorrhage in the intestines. In the lower portion of the ileum, three of Peyer's patches were softened, but not ulcerated. Some of the solitary glands were turgid. The mesenteric glands were congested, and of a rosy color. The spleen was enlarged, and in color was deep-red, like the lees of wine: its parenchyma was pulpy. The liver was soft. The posterior portion of the lower lobes of both lungs was the seat of apoplectic engorge- ment: the pulmonary tissue was soft and blackish. The membranes of the brain were only slightly injected. What is the mechanism by which intestinal hemorrhages take place in putrid fever? At the autopsy of persons who have died of dothinenteria we often find bare mesenteric vessels at the bottom of the intestinal ulcera- tions. Hence it might be supposed, that these hemorrhages are attributable to the rupture of a mesenteric vessel during the process by which the furuncular core is eliminated. Still, for the most part, if not always, this is not what occurs. The blood is exuded by the mucous surface, exactly as it is in htematemesis and epistaxis, as well as in many other similar circumstances. The immediate cause of this sanguineous exhalation is an essential change in the blood, which is in a dissolved state, a fact you can verify by examining the blood abstracted from patients in our hospital wards which are under the charge of physicians who have recourse to blood- letting in the treatment of typhoid fever. Such of you as have attended the excellent clinical lectures of my honorable and very accomplished colleague Professor Bouillaud, the most ardent advocate of this antiphlo- gistic method of treatment, are aware that the blood drawn in such cases from a vein, or obtained by cupping, presents a fluidity very different from that taken in acute inflammatory diseases such as pneumonia and acute articular rheumatism. This particular condition of the blood, seen in a very high degree in the hemorrhagic putrid fever (a case of which I have just detailed to this decomposition of the blood is also met with in other fevers, for example, in yellow fever, that singular malady in which hemorrhages from the stomach and bowels are so pathognomonic, that in some regions of South America, and in the Antilles, where the disease is endemic, its common name is vomito negro or black vomit. In scarlatina, diphtheria, measles, and small-pox, the blood is generally in this dissolved 248 DOTHINENTERIA. state, and to it are attributable the intestinal, renal, and nasal hemorrhages met with in them, and of which I mentioned cases when treating of these diseases. Neither in these diseases nor in yellow fever are there intestinal ulcerations to which we can attribute the hemorrhages. Still, we can understand how the intestinal lesions of dothinenteria may favor the ten- dency to exudation of blood, just as in hemorrhagic small-pox, measles, and scarlatina, or in diphtheria, an excoriation of the nasal mucous mem- brane may favor the production of epistaxis, or a surface denuded by a blister may more readily become the seat of cutaneous hemorrhage. So far is ulceration of the intestine from being a condition essential to the production of hemorrhages, that they often come on at a period of the disease very far removed from that to which ulceration belongs. Four years ago, I was sent for to meet Dr. Olliffe ill consultation, in the case of a young Englishwoman who had been seized with intestinal hem- orrhage. In this patient, the hemorrhage occurred at the ninth day of putrid fever, a period at which the existence of ulcers was very improb- able, as they are seldom formed till the fourteenth, fifteenth, or sixteenth day. The hemorrhage continued for two days, and was so great as to cause extreme anaemia. On the fourteenth day of the disease, however, an obvious improvement took place in the patient's general state, and in seven days afterwards, she had completely recovered from the typhoid fever. All that remained of her attack was the anaemia consecutive on excessive loss of blood. I have asked myself whether the influence of a prevailing " medical constitution" might not sometimes explain the occurrence of these hemor- rhages. Some years ago, I was meeting with them in typhoid fever, and at the same time was also meeting with passive hemorrhages in other dis- eases : I had at that time cases of purpura hemorrhagica, black small- pox, and numerous examples of the petechial scarlatiniform eruptions, which I have pointed out to you as occurring at the beginning of varioloid affections. You have seen me treat intestinal hemorrhages with preparations of rhatany and sulphuric acid. I generally prescribe a mixture of four grammes of eau de Rabel, forty grammes of syrup of rhatany, and one hundred grammes of water, ordering it to be taken during the day in doses of a tablespoonful. To prevent a recurrence of the hemorrhage, I rely on cinchona: I prescribe four grammes of the powder of yellow cinchona to be taken daily in a small cup of coffee without milk. As a means of ar- resting the flux, this remedy certainly does not produce a sufficiently rapid effect; but for correcting the disposition to a recurrence, cinchona in pow- der is undeniably efficacious. Essence of turpentine has also been lauded by Graves in the treatment of these hemorrhages. Granular and Waxy Degeneration of the Striated Muscles in Typhoid Fever. -Nature and Consequences of this Degeneration.-Special Course of the Rise and Fall of Temperature in Typhoid Fever: this is Characteristic. -Parallelism between the Course of Temperature and the Evolution of the Intestinal Lesions. » A distinguished anatomist, Professor Zenker, when the prosector of my friend Dr. Walther of Dresden, discovered the existence of interesting anatomical lesions in typhoid fever-granular and waxy degeneration of DOTHINENTERIA. 249 the striated muscles.* Rokitansky had previously examined very thor- oughly the subject of the fatty variety of granular degeneration : Virchow afterwards gave a very exact description of waxy degeneration which he regarded as connected with myositis, and he explained by this secondary alteration the rupture of muscular fibres observed most frequently in cases of typhoid fever : but Dr. Zenker has studied with the greatest care, and upon a considerable number of subjects, the different phases of the altera- tions which take place in muscles in typhoid fever. You must remember that this kind of degeneration is not peculiar to typhoid fever: it has been observed in several other diseases. Without inquiring what it may be in the abstract, let us now describe what has been observed in relation to it in dothinenteria. In typhoid fever, different groups of striated muscles are subject to de- generation, variable in intensity and extension, but not less constant than the characteristic dothinenteric lesions of the mucous membrane of the in- testines. This degeneration is either granular or waxy. Granular degeneration, when examined with the aid of the microscope, is found to be characterized by a deposit of extremely minute molecules in the contractile tissue of the muscular bundles. This induces very great fragility in that tissue, so that during life, muscular contraction may cause rupture of the affected fasciculi. In' waxy degeneration, the contractile tissue of the primary muscular fasciculi is transformed into a colorless and perfectly homogeneous mass, presenting a very decided waxy lustre. The transverse strise and the nu- clei have entirely disappeared, and the sarcolemma remains intact as in granular degeneration. The waxy-looking substance is a protean body, resulting probably from a transformation of the fibrin or syntonin. The altered fasciculi are always found to have acquired increased volume, and are sometimes twice their natural diameter. As in granular degeneration, they are found to have become exceedingly fragile, and to be the seat of numerous transverse fissures. In addition to the rupture of muscular fibres, the rupture of vessels may likewise occur, as a consequence of granular or waxy degeneration : and this leads to small ecchymoses, or infiltrations of blood, more or less exten- sive in proportion to the thickness of the altered muscle, and the diameter of the ruptured vessel. These hemorrhages occur most frequently in the second or third week of the disease. Suppuration is a sequel of muscular degeneration which occurs much more rarely than rupture of vessels. But it would appear that degenera- tion of the contractile tissue is not always the cause of the suppuration, which latter may be the result of irritation seated in the perimysium (or envelope of the primary fasciculi). It is, therefore, the perimysium which would suppurate. Generally, there is only cellular proliferation of the perimysium, that hyperplasia being limited to the work of muscular regen- eration : but there may be a greater amount of local irritation, so as to cause the limits of normal hyperplasia to be exceeded, in which case there will be more cells formed than can :yl vance through the stages required for their becoming contractile tissue: the cells which are in 'excess will therefore be devoted to destruction, and be transformed into pus. This is the histological explanation of the inflammation, and subsequent suppura- tion of, the muscular tissue. * Zenker : Sur les Alterations des Muscles Volontaires dans la Fievre Typhoide. [Archives Generales de 1866 ] I am indebted to this work for most of the details which I give above on the degeneration of muscles in typhoid fever. 250 DOTHINENTERIA. The association in the same muscle of granular and waxy degeneration, according to Dr. Zenker, does not prove that the waxy, which is the more serious of the two, is the ultimate result of the granular. From their very commencement, the two forms of degeneration are distinct from each other. To the naked eye, the following are the appearances which altered mus- cles present: they seem perfectly intact, when the degeneration is but little advanced, which explains how this condition escaped notice prior to the employment of the microscope: when the lesion is greater, there is a very apparent change of color, and in proportion as the degeneration increases, the discoloration becomes more decided: the muscles have at first a rose- gray tint which, becoming gradually paler, is finally yellowish-gray, with sometimes a very slightly reddish or brownish color. The discoloration proceeds by small spots or lines corresponding to the points where there is degeneration. When cut into, the altered muscles present an appearance resembling the flesh of fish. During the first phases of the degeneration-the second and third week of the dothinenteria-the affected muscles are in general very tense, smooth on the surface, and in their substance dry, friable, and easily torn. They are increased in bulk, which arises from the thickening of the degenerated primary fasciculi. In the more advanced stages of the degeneration the muscles are relaxed, the surfaces of a section often present a humid aspect, and there is even sometimes more or less infiltration of serum not only into the muscle, but also into the loose cellular tissue which surrounds it, there being no similar infiltration in other parts of the body-a circumstance which proves that it is the result of the morbid changes in the muscle. My friend Mr. Walther has frequently seen on the living subject, over the recti muscles of the abdomen, a slight oedema corresponding to the lesion I have been describing, and recognizable by making strong pressure upon the part with the finger. I confess to you that I have not been so fortu- nate as to find this appearance. According to Professor Zenker, muscular degeneration always occurs in typhoid fever : in every autopsy he has found it, when he looked for it. The waxy is much more common than the granular alteration : Professor Zenker met with the former seventy and the latter 6nly nine times. The process of degeneration is generally at its height towards the end of the second week, from which it may be inferred that alteration commences as early as the disease itself. It continues with undiminished intensity during the third and fourth week. It is about this period that absorption of the detritus of the altered muscular tissue seems to take place: this leads to softening of the muscles, often accompanied by serous infiltration, and the possibility of observing, like M. Walther, a little oedema during life. These details in pathological anatomy are too full of interest for me to refrain from making you acquainted with them. The constancy of the occurrence of muscular degeneration in typhoid fever proves that it is an integral part of the disease, and the generalization of the lesion shows that it is not the accidental result of a morbid action exclusively local, but the expression of a general disturbance of the economy; the muscular system is attacked, just as the other systems are attacked. Here again, however, gentlemen, I much fear that a consequence has been mistaken for a cause. It is evident that the weakness and disorder of the locomotive functions which cause the patient to totter from the very beginning of an attack of dothinenteria cannot be due to muscular degenera- tion, inasmuch as it does not then exist, or at least has only begun. The func- tional disturbance is caused by the morbid state of the cerebro-spinal system. DOTHINENTERIA. 251 The general disturbance of all the functions, and the special disturbance of the muscular system, which we see in dothinenteric patients, arise from imperfect innervation. It is at a later stage of the disease that granular and waxy degeneration of muscles is produced by alterations in nutrition, consequences of disordered circulation. Disorder of the circulation pro- duces hypersemia everywhere, and everywhere consecutively, either pseudo- inflammations (long ago described), or the forms of degeneration upon which I have been addressing you. It is, then, in a somewhat advanced period, and particularly during convalescence, that the granular and waxy degeneration of the muscles affords a physical explanation of the feebleness which is felt. Besides, I cannot refrain from remarking that the degeneration affects in the greatest degree the recti muscles of the abdomen and the adductors of the thighs, which certainly are not the prin- cipal muscular performers in the act of locomotion. We must, therefore, while we record as interesting the anatomical details which I have given you, seek elsewhere for the cause of the long-continued feebleness of doth- inenteria : the cause is exhaustion-exhaustion from the morbid poison which produced the fever-exhaustion from every kind of affection ©f the nervous system, such as sleeplessness, delirium, and convulsions-exhaustion from diarrhoea-exhaustion from suppuration in the situation of the sloughs -exhaustion from embarrassment in sanguification-exhaustion, finally, from inanition. Is there not in this more than enough to account for the feebleness, without requiring to seek an explanation of it in the partial alteration of the muscles? And do you not agree with me in thinking that it amounts to a sort of trifling to give or to accept such an explanation? Gentlemen, I am now going to give you an account of the valuable clinical information which the thermometer furnishes in dothinenteria. At the beginning of this fever the temperature rises slowly, just as the symptoms are slow in developing themselves. During the first three, four, or five days, the temperature is from eight-tenths of a degree to one degree higher than on the previous evening, while on each succeeding morning there is a slight remission of about five-tenths of a degree from the temper- ature of the previous evening. Thus, in each twenty-four hours there is observed an increase of temperature both in the morning and evening, as compared with the morning and evening of the preceding day, although there is every twelve hours a slight remission in the morning, as compared with the temperature of the preceding evening. Here is a table exhibiting this movement of temperature, as it occurred in one of our patients during the first four days : Day of the disease. Morning. Evening. Exacerbation between morning and evening. Remission be- tween evening and morning. Rise between mornings. Rise between evenings. Degrees. Degrees. Degrees. Degrees. Degrees. Degrees. First, . . 37. 38.2 i.2. Second, 37.8 39 2 1.4 J 0.4 0.8 1. Third, . . 38.4 39.8 1.4 } 0.8 0.6 0.6 Fourth, 39.4 40.4 1.} 0.4 1. 0.6 5. 1.6 Definitive elevation of temperature up to the evening of the fourth day, 3.4°. This table, drawn up by my chef de cltnique, M. Peter, shows you at a glance the progressive ascent of the temperature, which, although there 252 DOTHINENTERIA. was a daily remission every morning from the temperature of the previous evening, had a positive increase every twenty-four hours both morning and evening. You will also observe from the table, that if the temperature had always remained in the morning at the point at which it was on the pre- ceding evening, there would have been at the end of the fourth day a de- finitive elevation of five degrees, but as it fell every morning, the actual increase was only 3.4° over the temperature of the first day. The table also shows you, that on the evenings of the third and fourth days, the tem- perature was oscillating at about 40 degrees, that is to say, between 39.8° and 40.4°. This is about the usual temperature at that period ; and for a long time the average of the evening exacerbation is 39.5°. From these facts, which were first ascertained by Thierfelder, the following conclusions have been deduced by Wunderlich : When the temperature is 40° from the first or second day of the attack, the disease is not typhoid fever: and again : When by the evening of the fourth day, the temperature has not attained 39.5°, the disease is not typhoid fever. Need I, gentlemen, insist upon the clinical importance of these state- ments? With their assistance you can from the very first make a differen- tial diagnosis between dothinenteria, ephemeral fever, and an eruptive fever, such for example as scarlatina, and at the fifth day of a case hitherto doubtful, you will be furnished with data for stating that it is not dothin- enteria. Let me give you the proof of this statement, derived from an excellent little work by Dr. Ladame of Neuchatel, from which I have taken numerous extracts: "At the beginning of January, 1864," says this young physician, "I was appointed to take the place of one of the internes of Professor Griesinger, who had charge of the typhoid fever patients in the building set apart for contagious diseases in the cantonal hospital of Zurich. The cases at that time were very severe and numerous, and the student whose post I took was ill of the fever, which he had contracted by contagion. When I had been but a few days on duty in the fever wards, I was seized one morning, during the clinical lecture, with slight shivering, great prostration of strength, ano- rexia, and violent headache. I went to bed under the conviction that I was at the commencement of an attack of typhoid fever. In the evening I took my temperature. The thermometer rose to 40 degrees! Notwithstanding the high fever from which I suffered, I was quite tranquillized as to my state. Next morning, convalescence began. The only treatment I had was low diet, cooling drinks, and one centigramme and a half of acetate of morphia."* I have just told you that in our patient the temperature gradually rose during the first four days of the first week. In the three last days of the same week, it was 40.6° in the evening, and fell between six and eight-tenths of a degree in the morning. This is what generally takes place in the second half of the first week: the evening temperature keeps up to at least 39.5°, and usually to 40° or more, the morning temperature, according to the researches of Wunderlich, always remaining half a degree lower. Hence you perceive, that if you are called to a patient who has been confined to bed for some days, and has symptoms which lead you to suspect dothin- enteria, you can decide that it is not that disease if the thermometer does not indicate an evening temperature of 39.5°, or if it on any one morning show the normal temperature of 37°. At the end of the first stage, that is to say of the first week, the tem- perature has reached the point at which it will remain during the whole course of the fever. It oscillates about 39.5°, which it rarely exceeds in * Paul Ladame : Le Thermometre au Lit du Malade. Neuchatel: 1866. DOTHINENTERIA. 253 the evening, and in mild cases almost never attains in the morning. In some severe cases, the temperature exceeds 39.6° in the morning, as well as in the evening. I have hitherto spoken of the diagnostic indications furnished by the thermometer. I now proceed to speak of it as a guide to prognosis. Ac- cording to Wunderlich and Ladame, it is during the second week that one can best prognosticate the course of the disease from thermometrical obser- vations. 1. If the evening temperature is maintained between 39.5° and 40°, and the morning temperature remain always from half a degree to a degree lower than that of the previous evening, the attack will probably be mild, and convalescence begin about the third or fourth week, particularly if the temperature commence to fall a little between the eleventh and fourteenth days. 2. When during the second week, the temperature of the morning is maintained at 39° or 39.5°, and when the evening temperature reaches.or exceeds 40.5°, without any commencement of a diminution of heat being observable by the middle of that week, there is a certainty that conva- lescence will, at the soonest, not begin before the fourth week. 3. All irregularities of temperature occurring during the second week demand attention. 4. Even when the temperature does not rise above 40°, the absence of a remission during the latter half of the second week, or an increase of tem- perature toward the end of that week, are always unfavorable signs. 5. The case is very serious, when the temperature is at 40° or more in the morning, and 41° or more in the evening; or when, towards the end of the second week, the temperature goes on increasing. Speaking generally, it may be stated that a temperature of 41° is not often met with, and in general only in cases which terminate in death. Mark the great prognostic value of this figure! A temperature of 41.5° or 42° indicates inevitable death. The prognosis is also unfavorable when the morning temperature reaches or exceeds 40° for several days in succession. Let me here notice, in relation to prognosis, this very high temperature, and extreme frequency of pulse. Dothinenteria is not a disease in which the pulse is very frequent, the normal range being from 100 to 110. When it gets up to or abave 120 in an adult suffering from this fever, the prog- nosis is as unfavorable as when the temperature reaches or exceeds 41°. 6. From the commencement of the third week, the mild and serious cases can be distinguished from each other with the greatest precision. In the mild cases, there are great remissions of heat in the morning, the morning temperature being a degree and a half or even two degrees lower than that of the previous evening. During this week, the morning temperature be- comes normal, and the evening temperature likewise goes on falling rapidly, but does not reach the normal standard till about the middle of the fourth week. In bad cases, on the other hand, the temperature remains what it was during the second week; and it is only at the end of the third, or be- ginning of the fourth week, that great remissions of temperature take place. 7. Defervescence never proceeds so rapidly as in exanthematous typhus.* It takes place in different ways. The most usual manner is by the tem- perature beginning to fall considerably in the morning, even when, as I have just said, the evening exacerbations continue the same for some days; thus you may have, I repeat, a normal heat in the morning, while the even- ing temperature may still be 39° or even 40°. At other times, defervescence * See the Lecture on Typhus in this volume. 254 D0T1IINENTERI A. goes on in a regular and parallel manner, morning and evening, during a period of eight or ten days. 8. Convalescence may be said to have begun, when the evening tempera- ture has returned to its natural standard of 37°. 9. The temperature generally rises at the time of death, or a few hours before it. Drs. Thomas and Lade found the temperature as follows, imme- diately before death in fourteen cases: Five times, from 40.25° to 40.70°. Twice, " 41.12° " 41.25°. Seven times, " 42° " 42.75°.* In seven of the cases, therefore, the temperature reached or exceeded 42°, a temperature which according to Wunderlich is hyperpyretic, and only met with in cases which terminate in death. Under such circumstances, there is almost always a predominance of nervous symptoms, such as furious de- lirium, excessive restlessness, exhaustion, and paralysis. Nevertheless, in contrast to these cases, I ought to tell you that there are others in which the temperature is normal, or very low. The pulse is at the same time small and very frequent: the skin is covered with a cold sweat: the extremities are livid: and in a word, the patient dies in a col- lapse, which is sometimes preceded by hemorrhage. Finally, there are cases in which death takes place although the tem- perature has neither been very high nor very low ; the patients die ex- hausted after a profuse and obstinate diarrhoea, accompanied by tympanites, and nervous symptoms of no very great severity. The thermal condition and the intestinal lesions follow an almost strictly parallel course. You will remember I told you that the alteration in the glands of Peyer and in the solitary glands begins on the fourth or fifth day ; and I have now to say, that it is from the same period that the tempera- ture rises definitely to somewhere about 39.5° or 40.° There is, therefore, you see, a parallelism between the two phenomena. I have also told you that in mild cases the lesion of the Peyerian patches may be proceeding towards resolution: now, in mild cases, it is precisely at this time-about the middle of the second week-that we observe the great morning remis- sions of temperature. The parallelism continues: at the end of the third week, resolution of the Peyerian patches may be complete; and that is the period at which the evening temperature becomes normal. I also told you that in the most severe cases, resolution proceeded in certain patches, whilst others increased in size, and became more and more affected ; so that in this way, the intestinal lesion continued till the third or even fourth week ; and we have just seen that in severe cases defervescence does not begin till that period : here again is parallelism. To sum up: In the first period, or the period during which the intestinal lesions are formed and developed, and which extends from the first day of the attack to the second half of the second week, the fever is continued or slightly remittent, that is to say, that in the morning and evening the temperature is febrile : in the second period, or period of resolution, embrac- ing the third week and more, the fever is intermittent, that is to say, the temperature is febrile in the evening, and normal in the morning. During convalescence, there is no fever, and the temperature is either normal or low both in the morning and evening. Finally, to give a general idea of the thermal movement in typhoid fever, it may be said that there is a slow and gradual upward movement of the curve from the beginning of the dis- * A. Lade: Recherches sur la Temperature dans les Maladies. Geneve: 1866. DOTHINENTERIA. 255 ease; then a state, nearly stationary, in which there is only a slight morn- ing descent; after which comes a regular but a slow defervescence. In conclusion let me add, that when defervescence does not take place at its proper time, or when the temperature rises at the time at which defer- vescence ought to begin, there is a complication for which, if its nature is not evident from the symptoms, you ought carefully to search. There again, gentlemen, the thermometer may assist you in dealing with an insidious affection.* Rosy Lenticular Spots.-Successive Eruptions.-Miliary Eruption.-Blue Spots. I have already said, gentlemen, that while I disagree entirely from those authors who hold that the rosy lenticular spots constitute the specially characteristic eruption of dothinenteria, and who look on the intestinal lesion as a secondary affection, I do not the less admit that the cutaneous eruption is of very great importance in the symptomatology of the disease. The slightly prominent rosy papules, which disappear under the pres- sure of the finger, do not begin to show themselves till from the seventh to the tenth day of the fever, and it is not unusual for their appearance to be even longer delayed; but when this delay occurs, the general symptoms, which till then have been very mild, become strongly marked. It was so in the case of a young man in St. Agnes's Ward, who after having shown us no symptoms for fourteen days, except a little prostration without fever, and a slightly saburral tongue, was, at that period of the attack, and coin- cidently with the appearance of the cutaneous typhoid eruption on the abdomen, seized with symptoms of the most serious character. There are also cases in which the cutaneous eruption never appears during the whole course of the disease, a fact to which I have already called your attention, by mentioning that in some epidemics of certain departments in France, it had not been met with. This eruption does not come all out on the skin at once, as is the rule in the exanthematous fevers. Some papules first show themselves: on follow- ing days others consecutively appear. Each papule considered by itself has a duration of from three to fifteen days, and those which appear first are fading when new ones are coming out. The total duration of the whole eruptive period averages eight days, but it varies between the extreme terms of three days and twenty days. Its profusion and prolonged duration generally coincide with an excep- tional severity, or, to express it more correctly, with a greater prolonga- tion of the disease. You have been frequently in a position to verify this statement for yourselves in numerous cases which have been brought under your notice. Thus, in two cases in which there was a total absence of the rosy lenticular spots, you saw recovery take place at the end of the third week, reckoning from the time at which the patients were obliged to remain in bed, till the day on which convalescence was thoroughly established. This was also the duration of the illness in six other individuals who had the usual number of spots, but it was longer in eleven patients in whom you saw a very confluent eruption. The coincidence which I am pointing out, in the confluence of the spots and the severity of the disease, is never * Alf. Duclos : Quelques Recberches sur 1'etat de la Temperature dans les Maladies. Paris, 1864. Hirtz : Article " Chaleur" dans le Dietionnaire de Medeeine et de Cbirurgie Pratiques, T. vi. Paris, 1867. 256 DOTHINENTERTA. more evident than when the eruption after having disappeared comes out again once or several times. Simultaneously with the appearance of new spots, which are often more numerous than their predecessors, the general symptoms acquire new intensity. A woman, aged nineteen, who occupied bed No. 25 of our St. Bernard Ward, was attacked, eight days before admission, with headache, pain in the abdomen, and a feeling of general lassitude, prostration, and pains in the limbs. The abdomen was not tympanitic, but pressure caused gurg- ling in the right iliac fossa. The fever was rather moderate. Typhoid spots were visible when the patient was admitted into hospital: that first eruption disappeared, and a second showed itself on the eighteenth day, at a time when there had been an amelioration in the general symptoms for four days. Simultaneously with the second appearance of the spots, there was a renewal of the other symptoms in an aggravated form: the prostra- tion was greater, the fever higher, and the diarrhoea more profuse than be- fore. Five days later the severity of the symptoms subsided, and on the twenty-seventh day from the beginning of the attack the patient was quite convalescent, and five days afterwards was in a state to leave the hospital. In the case which I am now going to relate there were two Reappear- ances of the cutaneous eruption. The patient was a young woman whom you saw occupying bed No. 30 in the same ward. When received into the Hotel-Dieu she had been ill fifteen days, and ten days confined to bed. She had all the symptoms of typhoid fever. We found numerous rosy spots. They had disappeared on the thirteenth day of the attack: next day an improvement was observed, there being less diarrhoea, tympanites, and pros- tration. Three days later the patient experienced nausea :• there was a renewal of the abdominal tympanitic distension, and at the same time gurg- ling was perceived. There was high fever, and a new eruption as abundant as the former. The severity of the symptoms after a time abated. The spots were completely faded on the twenty-seventh day ; and on the thirtieth convalescence seemed sufficiently secured to enable the patient to be allowed a little solid food ; but, on the thirty-fourth day, there set in, for the third time, abdominal pains, gurgling, nausea, vomiting, and diarrhoea. The tongue was red, dry, and destitute of epidermis; the skin was hot, and the urine contained albumen, which coagulated on the application of heat. On the morrow a new eruption of rosy spots appeared, which remained till the fortieth day of the disease; and on the forty-fifth day convalescence was definitely established. In neither of these cases could any cause be assigned for the severe relapse of the dothinenteria; but relapses are sometimes attributable to errors in diet, to a fit of indigestion, so difficult to guard against in self-willed patients. This occurred in a third case in which there was a return of the symp- toms. The patient occupied bed No. 5 of St. Bernard's Ward. On the twenty-eighth day of her dothinenteria this woman, who was entering upon her convalescence, had a fit of indigestion, and was very soon afterwards seized with delirium and fever. On the following day an eruption of rosy spots-which had been observed since her admission to hospital and had disappeared-again came out. The relapse was not of long duration. The general symptoms abated: the spots had faded away in five days from the date of their reappearance, and by the end of the fifth week recovery was complete. The existence of this exanthematous eruption at periods very remote from that before which it has generally disappeared may sometimes lead to mis- takes ; and when one has not observed the disease from the beginning, when there is a want of precise information regarding the previous history of the DOTHINENTERIA. 257 case, the dothinenteria may be supposed to have reached a more advanced stage than it really has. An autopsy recently performed in your presence has a very interesting bearing on that point. A man, aged thirty, was brought to the hospital with all the symptoms of very severe putrid fever. The delirium was violent, the fever intense, the skin hot and dry: the abdomen was tympanitic, and covered with a very confluent eruption of rosy lenticular spots. Although the persons who brought him to the hospital told us that he had been ill thirty-five days, the profuse eruption led us to believe, considering the general rule of the disease, that the typhoid fever dated back only sixteen or eighteen days. We inquired whether the patient had not had some other malady before that under which he labored at the time of his admission to the hospital. The patient died; and, on opening the body, it was found that the typhoid fever really did date back to a period thirty-five days before we saw him. We found intestinal ulcerations nearly cicatrized. The eruption which he had on admission was therefore a second eruption. To explain the intensified returns (recrudescences) of the fever and the successive eruptions, we must suppose that the morbid poison has not ex- hausted itself in the first outbreak, and that the economy, to get rid of it, requires repeated efforts. These returns of the fever are neither relapses (rechutes), nor still less are they new attacks (recidives') : it is the same attack, the symptoms of which, temporarily interrupted, recur under the influence of the same morbid cause which produced them in the first in- stance. However complete the symptoms may be, and although the erup- tion reappears, the characteristic intestinal lesion never returns. In the patient whose case I have just brought before you, we only found cicatrized ulcerations: there was no trace of a renewal of the intestinal ulceration. The possibility of the symptoms returning at a time when convalescence is supposed to have begun ought to make the physician very cautious. When at this period he thinks that he may feed up his patient, he ought to proceed with very great prudence, and avoid being guided by the appe- tite of the patient, which is often deceitful: he ought in particular to be exceedingly reserved in his prognosis during the whole course of dothinen- teria, as cases which seem at first to be exceedingly mild, may one day have a very serious exacerbation. In reference to successive eruptions, I would say, that while they do not absolutely imply danger, they at least indicate that the case will be more protracted than usual, and consequently that recovery will be retarded. I have still to mention two other forms of eruption to which I have often directed your attention at the bedside of the patient. I am not at present referring to petechice, those small spots of a violet-red color, which do not disappear under pressure of the finger, true subcutaneous ecchymoses, which belong to the history of hemorrhagic putrid fever, and still more to the history of typhus. I refer to the miliary eruptions and the blue spots. The transparent miliary vesicular eruption [la miliairepellucide] improperly called sudamina, generally appears between the eleventh and twentieth days and sometimes later, and consists of small blebs of round or oblong shape like tears, which are filled with a transparent fluid. This eruption is some- times very profuse, but there is a great difference in respect of the number of blebs. The situations which it occupies are the abdomen, particularly in the vicinity of the groins, the front of the neck, and the anterior part of the axillse: in some cases it extends over the entire trunk, and also appears on the limbs. This eruption is hardly visible, unless you are very close to the patient, but it is easily recognizable by the touch, on account of the sort of rugosity of the skin caused by the small blotches of which it con- VOL. I.-17 258 DOTHINENTERIA. sists. It is never seen on the face. It is more usual to meet with this exan- them in typhoid fever than in any other disease, but it is by no means pecu- liar to it; and I agree with Huxham and Professor Bouillaud in regarding it as simply the symptom of a symptom, miliary eruption being generally the consequence of sweating. You have seen in many patients an eruption of spots of a blue color. These blue spots, you have remarked with me, are only seen in exceedingly mild cases terminating favorably. Is this a mere coincidence, or is the eruption of blue spots an inherent characteristic of a mild form of the dis- ease ? These are questions which I cannot solve. Intestinal Dothinenteric Catarrh.-Its Specific Character.-Predominance of Intestinal and Pulmonary Catarrhal Affections constitutes the Forms of the Disease called "Abdominal" and " Thoracic." We had, gentlemen, in bed No. 11 ter of St. Agnes's Ward, a youth who came into the Hotel-Dieu five days ago with giddiness, headache, high con- tinued fever, the tongue red at the point, thirst, anorexia, some fits of cough, and a profuse diarrhoea. At first, there was room for supposing the case to be one of incipient typhoid fever, and for a moment I did entertain that idea. The diarrhoea, however, had set in so suddenly, and had from the very first been so severe, that I hesitated: the symptoms seemed not to be those of the enteritis which accompanies putrid fever, but those rather of simple intestinal catarrh. I deferred my diagnosis; for it is especially necessary in such circumstances not to pronounce a too absolute opinion. In twenty-four hours, the fever had abated, and on the third day it en- tirely ceased: the general symptoms likewise improved, the headache be- came less severe, the appetite returned, and with these changes for the better, the diarrhoea also stopped. In fact, this youth who, at the most, had been ill six days, had, at the end of these six days, regained his usual health. I should certainly, gentlemen, have played a lucky game, if I had given at my first visit a decided opinion based upon the symptoms which were then present. If without allowing the case for a moment to follow its natural course, I had begun active treatment, in place of confining myself to prudent waiting, I might have believed, and I might have told you, that I had cured a case of dothinenteria in six days, as some physicians who do not take into account the specific character of the disease assert they can do, and as homoeopaths particularly pretend to do. I should have deceived myself like these physicians, and like these homoeopaths: I speak of honest homoeopaths, for it is necessary to distinguish between the honest and dishonest of that sect. Of the dishonest homoeopaths, the great majority, grossly ignorant, and without any kind of medical creed, only see in homoeopathy a road to riches, by attracting to themselves the public, always favorable to the mysterious; while others, still more culpable, shame- less charlatans of the worst description, educated in our art, knowingly deceive themselves in deceiving their patients. But by the side of these dishonest men, thoroughly deserving of the contempt into which they have fallen, there are others, educated, conscientious, and convinced of the truth of the doctrine which they have embraced : it was to them only that I made allusion. Well! when these practitioners fancy that they have arrested in their career maladies which must pursue an inevitable course, it is because they do not regard this inevitability from the same point of view with me. Let me explain myself by giving you an illustration of my meaning. We know beforehand, when we inoculate small-pox or cow-pox, that the morbific DOTHINENTERIA. 259 germs will grow up and produce a disease, the characters of which will be rigorously determined by, and absolutely dependent upon, the nature of the cruise whence they spring-as absolutely-the comparison is strictly correct-as absolutely as the germ of a plant grows up reproducing the characters of the species which furnished it, and of no other species, the acorn reproducing the oak, and the seed of corn reproducing corn. In disease, though we cannot lay hold of the first cause, the same thing takes place, that is to say, different causes engender diseases of different species having respectively their special symptoms and peculiar career; and, to return to our subject, the morbific cause which engenders simple intestinal catarrh, will not engender the catarrhal enteritis of dothinenteria anymore than the virus of small-pox will engender scarlatina : each has its own special characters and course, and I am not of those who believe that the one can be transformed into the other, unless it be under peculiar circum- stances, as for example, when, under an epidemic influence, an individual seized originally with a simple intestinal catarrh is attacked with putrid fever, which then puts its stamp on the non-specific enteritis. To continue still farther our comparison derived from the germination of the seed, I would remark, that while it is difficult, even after long practice, to distin- guish the different kinds of plants at the period when there is nothing to be seen but the nascent leaflets in the cotyledons of the seed, while we must wait till the formation of the plant is more advanced before we can tell the family, genus, species, and variety to which it Ifblongs, it is also diffi- cult to distinguish the particular disease with which one has to do, so long as it is only beginning to manifest itself. Hence the frequency with which simple intestinal catarrh is mistaken for the intestinal catarrh of dothinen- teria ; and the frequent necessity of allowing some days to elapse before pronouncing a decided diagnosis. It is, therefore, an immense point in medicine to know the natural course of diseases, and to wait a little till their characters are precisely drawn : before beginning treatment, it is necessary to know whether the case is one in which our intervention ought to be active, or one in which we ought to rely on the unaided therapeutic efforts of nature, satisfying ourselves by being always ready to assist na- ture should that be requisite. The intestinal catarrh of dothinenteria is a catarrh of a specific charac- ter, and we may use means for moderating it, just as we adopt means for moderating other catarrhs; but if we try entirely to remove it, we shall fail. The diarrhoea which characterizes it is one of the most frequent symptoms of the disease; but no more than the other symptoms is it pro- portionate to the extent or intensity of the intestinal lesions. It may set in during the first twenty-four hours, or not till the third day, the ninth day, or even not till a more advanced period ; and in some exceptional cases, the intestinal flux is absent, and sometimes even there is obstinate consti- pation during the whole course of typhoid fever. You have seen several examples of this in the clinical wards. In the generality of cases, the stools are few and scanty at the beginning of the attack, and vary during the remainder of its course in number and character. Sometimes a patient has only one in twenty-four hours, while another patient has more than twenty. The evacuations are liquid, yel- lowish, greenish, or sometimes they consist of a stercoraceous pulp, or they have a semi-liquid consistence; their odor is fetid, and sui generis. The motions are seldom accompanied by severe pain, and never or almost never with gripes; they may be passed involuntarily, as when the patient is in a state of delirium or stupor, and likewise when he is in no such circum- stances. 260 DOTHINENTERIA. The catarrhal feature of the disease is also met with in the pulmonary- apparatus, where auscultation always reveals a certain amount of bron- chitis, characterized by dry, moist, sibilant, and mucous rales, are heard from the beginning, or at least from the first days of the attack. The cough is generally in proportion to the abundance of the rales: the expectoration, which is exceedingly small in quantity, consists of mucous sputa. The catarrhal affections do not always coexist; and when the abdominal symptoms occur alone, or when they dominate over the other symptoms, " abdominal" is the name given to the form of the disease. It is chiefly in the mucous form of dothinenteria that we meet with this almost exclusively abdominal character in the symptoms. Thoracic complications, whatever may be the leading general symptoms, may assume great intensity, and then there may be either an exacerbation of the ordinary bronchial catarrh, or inflammation of the pulmonary parenchyma: the existence of pneumonia is ascertained by hearing fine crepitant rales and bronchial blowing on auscultation, and by dulness on percussion over the affected part. On examination after death, the lung is found to be highly congested, and hepatized, and to tear in handling, a condition which I remarked in the case of the young lad of St. Agnes's Ward, the particulars of which I will afterwards recapitulate. This pneu- monia occurring in the course of typhoid fever is one of the most serious complications: it greatly imperils the patient, and when it does not lead to an immediately fatal issue, it prolongs and thwarts convalescence. You saw to-day, in bed 28 of St. Bernard's Ward, a woman presenting an example of what is called the thoracic form. But in her case bronchial catarrh, without parenchymatous inflammation, is the leading symptom. The patient had bronchitis when she came into the Hotel Dieu on the loth of August last. She has resided in Paris for the last two years; she has generally enjoyed good health. She was confined seven months ago, when, fifteen days before she came into our wards, she was seized with headache, abdominal pain, and slight diarrhoea. From that time she was distressed by sleeplessness. When we saw her for the first time, she had a copious eruption of rosy lenticular spots. The circumstance which especially at- tracted my attention was, that the chief complaint this woman made was of difficulty in her breathing, which was loud and quick. On percussion of the chest, we found that the sounds elicited were everywhere equally clear: on auscultation, we heard rales in every part of the chest-mucous rales which were coarse at the upper part, and finer at the base of the lungs. The fever was very moderate. This patient is still in hospital, and in the report of her case, which is taken regularly day by day, you will see that her slight abdominal symp- toms had subsided by the 19th of August, that by the 21st the stools had become natural, and the fever had left her, but that the pulmonary symp- toms had improved very slowly. For some days, the expectoration has become more and more abundant, and has assumed a muco-purulent ap- pearance ; the plessimetric and stethoscopic signs remain as before, and there is no decrease in the dyspnoea. To-day, the thirty-second day of the disease, you see this woman still very much in the same state in respect of her bronchitis. You will find her seated on her bed, always suffering from oppressed respiration, and frequent fits of coughing. Her spittoon contains a large quantity of muco-purulent expectoration. The digestive functions, however, seem to have returned to their natural state, the appetite is re- stored, and she eats half the ordinary daily diet of a patient. There is very little feverishness. DOTIIINENTERI A. 261 Forms of Dothinenteria, viz., the Mucous, Bilious, Inflammatory, Adynamic, Ataxic, Spinal, Cerebrospinal, and Malignant. A mason, aged sixteen, born in the department of Haute-Vienne, and who had only been resident in Paris for a few months, came into the Hotel- Dieu on the 14th June, and was placed in St. Agnes's Ward. When I saw him next morning, he could not give the least information as to the begin- ning of the malady from which he was suffering. He was in a state of high fever; the pulse was 100, regular, but soft. There was profound coma; he had been delirious during the whole night; and I observed convergent strabismus of both eyes. The tongue was red and dry; the abdomen was tympanitic, with gurgling in the right iliac fossa, and diarrhoea. The symp- toms became more severe every day, and on the 17th I noted that the limbs were rigid. On the 19th, five days after his admission to hospital, the patient died. On the morning of his death, his appearance was deplorable; the eyes were haggard ; the nostrils, lips, and teeth were covered with black sordes; the tongue, dry and covered with little cracks, lay motionless be- tween the upper and lower teeth; the abdomen was tympanitic; the pulse was thready, and exceedingly quick ; the skin of the hands was cold, clammy, and blue as in cholera, while that of the body was dry and burning. At the autopsy, we found great gaseous distension of the intestines: the glands of Peyer were swollen, but not ulcerated, some of them forming an elevation of the thickness of a five franc piece: some of the solitary glands were swollen: the mesenteric glands were enlarged. The spleen was hyper- trophied, measuring seventeen centimetres in length and thirteen in breadth. Its tissue was easily reduced to a thin pulp. The liver, blackish and soft, broke down under the least pressure, making it difficult at first sight to dis- tinguish its two component tissues. The lungs, black, gorged with blood, and softened, tore easily: they did not contain any apoplectic sanguinolent masses. The heart, pale, and anamiic, contained some clots. The mem- branes of the brain were only slightly vascular: there was neither opaline nor even discolored effusion in the sulci: there was no thickening of the membranes, nor were they adherent to the substance of the brain. The brain, when sliced, presented only a slight appearance of bloody points. Gentlemen, during the two months which preceded the occurrence of this case, you saw two other typhoid fever patients in whom the symptoms which predominated were similar to those which we met with in this young man. One was a man, and the other a woman : both recovered. A month after leaving the Hotel-Dieu, the woman was received into La Pitie Hospital, having had a relapse. The man, aged eighteen, whose life was for a long time in danger, left our wards on the thirty-fourth day, completely recovered from the attack of typhoid fever, and also from sores over the sacrum which had formed during the severe period of his illness. These are cases of adynamic typhoid fever, which our predecessors con- sidered a distinct disease; just as the mucous, bilious, inflammatory, ataxic, and malignant forms were looked on as separate diseases till the progress of pathological anatomy, influenced mainly by the labors of Bretonneau, showed that they were not different species, but simply varieties of one species. Nevertheless, in reducing all the varieties to a pathological unity, spe- cially based on the constant existence of the dothinenteric eruption, it is impossible to deny that predominance of a certain class of phenomena gives a particular stamp to the dothinenteria, which it is important to take into 262 DOTHINENTERIA. consideration at the bed of the patient, in respect both of prognosis and treatment. Is not this predominance of particular pathological manifesta- tions conspicuous in other diseases, upon which it, in the same way, im- presses its own character? For example, does not pneumonia, generally an acutely inflammatory disease, become, under certain circumstances, bilious, adynamic, ataxic, or malignant ? In consequence of dothinenteria having a greater tendency than any other disease to present variety of dom- inant symptomatic phases, the older physicians, unable to grasp the patho- logical unity of this variety, regarded each different form as a distinct disease. The simplest form of dothinenteria is the mucous: it is distinguished from the others by its purely negative characters, there being no decided pre- dominance of one or several symptoms. You have seen numerous exam- ples of this form. To it belonged the cases in which the patients reached the hospital in a state of prostration approaching insensibility, complaining of a little headache, and feeling giddy. Some have had sleeplessness, and others slight delirium. The fever was moderate, and the pulse was often below the normal standard. You have sometimes observed epistaxis at the beginning of an attack: but it is generally absent, and the course of the disease is not influenced by its presence or absence. You have seen that the leading symptoms are connected with the diges- tive functions. The patients complained of want of appetite, an insipid taste in the mouth, and rather urgent thirst. The tongue, saburral to a slight degree, was covered with a thin whitish fur: it was moist, swollen, retained the impression of the teeth, and was red at the point and edges. In some cases, there was vomiting. Some patients had profuse bilious diar- rhoea, while others had obstinate constipation. Gurgling in the right iliac fossa was always observed. Auscultation established the existence of bron- chitis characterized by sibilant, sonorous, and mucous rales, with occasional fits of coughing accompanied by mucous expectoration. In some patients, the rosy lenticular spots were wanting, while in others, they came out in successive eruptions. This mucous fever is a mild form of dothinenteria, but nevertheless an attack may be prolonged for twenty or thirty days, or longer. I have always seen it terminate favorably; but you must remem- ber that in this mild form of the disease, as well as in the still milder cases to which the designation of latent typhoid fever has been given, death may occur from an unforeseen perforation, from hemorrhage, or from one of those spontaneous attacks of peritonitis of which I have spoken. Conva- lescence is often very slow; and when this has been the case, I have seen relapses which were worse than the original attack. Under the prevailing influence of certain medical constitutions, the dis- ease assumes the bilious form. Although this form has lately occurred pretty frequently in town, we have not met with any well-marked cases of it in the clinical wards. Gentlemen, you know the characteristics of the bilious form of dothinenteria. The saburral condition is more decided than in the mucous form. The complexion is yellow, particularly on the alse of the nose, and in the naso-labial hollow: the sclerotic has an icteric hue: there is greater want of appetite than in the mucous form, and the patient complains of a very bitter taste in the mouth, accompanied by nausea, and vomiting of yellowish and greenish matters. The fur upon the tongue is thicker than in the mucous form of the disease, and has a greenish-yellow appearance, particularly at the base. There is also more headache. The bilious is generally combined with one of the other forms of which I am going to speak. The inflammatory is likewise generally combined with other forms of the DOTHINENTERIA. 263 disease. It is characterized at the commencement of the attack by intense fever, a pulse which is full and often bis feriens, a moist heat of skin, and, in a word, with the symptoms of general febrile plethora. This inflamma- tory condition, which, according to the prevailing medical constitution, is frequently met with, rarely continues from the beginning to the end of an attack: it usually gives place to an adynamic or ataxic state. Except in this last form-this state of prostration-the collapse of the animal functions, particularly of muscular contractility, is one of the most constant generic characters in all the varieties of typhoid fever. When it is not in excess of its usual degree, it does not call for more anxious con- sideration than any other symptom ; but when it becomes the predominat- ing character of the attack, and when with the prostration of the functions of animal life, there is combined collapse of the organic functions more im- mediately essential to the maintenance of life, a condition exists to which is given the name of adynamia. This adynamic typhoid fever, of which I have brought under your notice several examples, was characterized in our pa- tients by extreme softness of the pulse, by very dgep and protracted stupor, by very great insomnia, by quiet delirium, by muttering, by picking the bedclothes, by deafness, and by paralysis of the bladder requiring the use of the catheter. You recollect a woman who in her delirium refused to take food, and to whom it was necessary to administer soups by the oesopha- geal tube. In this form of the disease, the tongue is clammy and trem- bling, and the tongue, gums, and teeth are covered with black sordes. There is profuse diarrhoea, and an extreme degree of tympanites. In some epi- demics intractable vomiting has been observed. In this form of the disease, you will observe that the perspiration, breath, and urine have a fetid smell. There is a tendency to hemorrhages; and also to sphacelus, as is indicated by sloughs forming in the seat, the heels, and over the great trochanters, caused by pressure, contact with excrementitious matters, and still more by the general condition of the patient. The symptoms which I have last men- tioned-the very great fetor of the breath, sweat, and urine, and the ten- dency to hemorrhage and sphacelus-have been given as the characters of putridity, which must not be considered as quite the same with adynamia. This putridity is compatible with a high temperature, a turgid and very in- jected state of the skin and mucous membranes, a great increase of the pulse, and, in a word, with high fever; the causus of our predecessors was nothing else than this congestion, although true adynamia has as its lead- ing characteristic a state of fever either suspended or notably below that which is absolutely indispensable for the complete and regular accomplish- ment of the long sequence of pathological operations of which the organism is the theatre. The adynamic form of dothinenteria is serious, but less serious than the ataxic form, and medical treatment can often do a great deal to assist the failing powers of nature. The therapeutic indication is to excite reaction, and to fulfil that intention, stimulants and tonics are evidently the appro- priate remedies. Generous wines, and cinchona in various forms constitute the basis of the treatment. Stimulants such as ether and camphor, excitants such as am- monia and the acetate and carbonate of ammonia ought to be administered for the purpose of awaking-if I may use the expression-of awaking the organic powers, while tonics ought to be employed for maintaining them. As tonics auxiliary to cinchona, I may mention infusions of wormwood, ser- pentaria, anise, cascarilla, and all similar remedies. Malaga wine is pref- erable to other wines, whether French or Spanish: it may be given in spoonful doses every two hours, every hour, or even at shorter intervals, the 264 DOTHINENTERIA. quantity taken in the twenty-four hours being from 125 to 250 grammes. The ordinary tisane of the patient is a vinous lemonade with the addition of Seltzer water. Cinchona is prescribed in the form of extract, in doses of from four to ten grammes, in draughts ; or in the form of powder, in a cup of infusion of coffee without milk; or the sulphate of quinine may be ordered in doses of a gramme and upwards. As a beverage, a weak decoction of the bark sweetened with lemon syrup is employed. If the stomach does not tolerate this beverage, the decoction, with the addition of camphor, may be given as a lavement; or sulphate of quinine may be administered in the same man- ner, combined with musk, as in the following formula : sulphate of quinine, from one to four grammes ; sulphuric acid, enough to dissolve the sulphate ; musk, two grammes; and water, a hundred grammes. Fomentations of wine and camphorated alcohol are employed. In the clinical wards, I have seen benefit result from placing the patient in a mustard-bath. Two kilogrammes of the flour of mustard, made into a soft paste with water, are .tied up in a coarse cloth and put into the bath: the cloth is pressed sufficiently to give a yellow color to the water.* Under the influence of such baths you have seen improvement take place, the general aspect becoming better, the pulse regaining volume and diminish- ing in frequency, the blueness of the extremities giving place to the natural color of the skin, and the abdomen becoming softer. This treatment is re- peated every twenty-four hours: it is not discontinued till, under its in- fluence, the skin has regained its warmth, till the pulse has become firmer, and the senses, the motor apparatus, and the intellect, have emerged from their state of stupor and lethargy. It is especially in this class of cases that we require to give nourishment to the patients in accordance with my plan: this is a cardinal point in the treatment of dothinenteria; but I will reserve what I have to say upon this subject till I come to discuss it in a special manner. In the ataxic form of dothinenteria the symptoms are of an entirely dif- ferent description. There is no prostration, nor collapse of the animal functions; but they are in a state of disorder, incoherence, and discord. When the ataxia involves the vital functions over which the sympathetic nervous system presides, and the active and constant exercise of which is essential to the continuance of life, we say that the form of the disease is malignant. We must not, however, confound malignity with ataxia, a term which embraces everything, and strictly speaking specifies nothing, for its application has been limited, as I now limit it, to the cases in which the cor- relation of the animal functions is broken up. Ataxic typhoid fever, then, is characterized by disturbance of the nervous system: the cerebral symp- toms consist in more or less violent delirium, accompanied by cries, vocif- erations, disturbed sleep, nightmare, hallucinations of every kind, convul- sions, tetanic contraction of the limbs, strabismus, picking the bedclothes, spasmodic jerking of the tendons, and sudden exaltation followed by as rapid a collapse of the muscular power. There is intense fever. The pa- tient complains of excessive lassitude, cramps, very severe pains particu- larly in the lumbar region, and violent headache. This is the most mortal of all the forms of dothinenteria: it destroys pa- tients as if by a thunderbolt. We have seen it carry off in four days a * The mustard generally used in France is a much feebler irritant than English mustard, so that in place of two kilogrammes (a little more than four pounds) it would be, perhaps, sufficient to employ two pounds of English mustard.-Trans- lator. DOTIIINENTERI A. 265 young girl brought by it to our St. Bernard Ward. Five days previously, she had been in perfect health. I am enabled by a special circumstance to fix with precision the date at which her attack commenced : she was present at the public fetes given to celebrate the Emperor's marriage, and on the following day experienced the first symptoms of the disease from which she died. It began with violent pain in the head, and a state of insomnia dis- turbed by dreams and frightful nightmares. When brought to the Hotel- Dieu, she complained of racking headache, accompanied by pains, which were dreadful in the limbs, and still more dreadful in the loins. The fever was intense; the pulse was very rapid ; and the skin was burning, dry, and colored. When this young woman was admitted into our wards, she was subjected to the cold affusion. From this she experienced a little tempor- ary relief, but on the same evening she succumbed to the violence of the symptoms, which had never ceased for an instant. The autopsy disclosed the existence of one of the most confluent dothin- enteric eruptions which I ever saw; and it is a remarkable fact, that this was seen at the fifth day of the disease. In my early medical studies, I saw an exactly similar case in the practice of my illustrious master, Bre- tonneau, at the hospital of Tours. The predominance of ataxic phenomena may sometimes depend on the nervous temperament of the patients, or on moral emotions experienced before or during the attack; but generally, it is dependent on the charac- ter of the epidemic, and the prevailing medical constitution. Having now spoken of the symptoms referable to the brain, it is neces- sary that I should point out to you those to which dothinenteria gives rise in connection with the spinal marrow, to which the late Dr. Fritz, an ob- server of the greatest merit, has directed special attention.* I refer to lumbar pains, very similar to those which occur so often in small-pox, ac- companied sometimes, but not so frequently as in that disease, by incom- plete paralysis of the lower extremities, or more generally by cutaneous and muscular hypersesthesia, and by lancinating pains in the extremities : there are also rachialgic pains of greater or less severity in the dorsal region, often a very intense pain in the neck, shooting to the occiput, im- peding the movements of the head and neck, and sometimes causing, like the pains in the inferior extremities, a feeling of inconvenient stiffness in the muscles; and finally, there is acute sensibility to pressure made over the spinous processes of the vertebrae of the region of pain, thus indicating a true spinal hyperaesthesia. These symptoms, which are almost never absent, generally continue till about the middle or end of the first week, and then disappear, just as hap- pens in respect of the cerebral symptoms in a great many cases. But this is not the invariable course of events. And occasionally, just as cerebral disturbance is seen to be the predominating feature of an attack, so spinal symptoms may occupy the leading place in the symptomatology of dothin- enteria, and continue to do so till the advanced phases of the malady. But it is important to observe with Fritz, that even in cases in which the spinal symptoms have attained a very remarkable degree of severity, the autopsies, as well as the clinical observations during life, show that there was neither inflammation of the spinal marrow nor of its membranes accidentally complicating the typhoid fever. At the very utmost, it is only in an exceedingly limited number of cases, that one can in part at- tribute the spinal symptoms to congestion of the membranes of the spinal * G. Fritz : Etude Clinique sur Divers Symptomes Spinaux dans la Fievre Ty- phoide. Paris: 1864. 266 DOTHINENTERIA. cord : generally, the cord and its coverings present no appreciable material lesion. We may, therefore, admit with Fritz, that there is a spinal form of typhoid fever, when spinal symptoms predominate, just as we allow that there is a cerebral form when cerebral symptoms predominate. In the cases of which I speak, the complete series of spinal symptoms maybe observed: thus, in respect of sensibility, and occupying the most important place, is cutaneous hypersesthesia extending over a great part of the body, some- times involving the four extremities, the trunk and the neck, and often accompanied by muscular hyperaesthesia; then there is hypenesthesia ex- tending from the atlas to the sacrum ; then again there is, but not so fre- quently, rachialgia accompanied by shooting pains in different parts of the body, and suffering of almost unbearable severity in the superior, and oc- casionally, though not often, in the inferior extremities; also, pain in the loins ; violent pains in the chest; bilateral and symmetrical neuralgic pains in the trunk ; anomalous sensations of cold, formication, a feeling of prick- ing along the spine or in the limbs. Finally, along with this exaltation of the sensibility, we may have its extinction or perversion ; for example, analgesia and anaesthesia of the skin, and muscular anaesthesia. There is quite as much diversity in the disorders of the motor system : for example, we meet with paralytic symptoms, numbness of the extremi- ties, paraplegia, partial paralysis of the respiratory muscles, constipation, retention of urine, paralysis of the sphincters, spasmodic affections, dysuria from spasm, spasmodic contraction of the respiratory muscles and muscles of the extremities, stiffness of the muscles of the neck, contraction of the limbs, and even tetanic symptoms. In conclusion, let me point out, with Fritz, a special group of symptoms having its origin in the medulla oblongata, such as extreme dyspnoea inde- pendent of any affection of the respiratory passages or muscles, spasm of the pharynx and larynx, convulsive cough, aphonia, alalia, inability to use the tongue in mastication, spasmodic or rhythmic contraction of the sterno-mastoid and trapezius muscles, and paralysis of the pharynx. The spinal symptoms of typhoid fever are often accompanied by cerebral, thoracic, and other symptoms of great severity. The concurrence of spinal with formidable cerebral symptoms constitutes the cerebrospinal form of Wunderlich, which presents some difficulties in diagnosis. It is not by chance or indifferently that the spinal symptoms show them- selves: in children, in young women, and in anaemic subjects, the spinal marrow seems to be peculiarly liable to be seriously affected in dothinen- teria. Independently of the treatment which ought to be pursued, in accord- ance with indications of which I will speak when reviewing the general question of treatment in typhoid fever, the cold affusion is of essential use in the ataxic form of the disease. When lecturing on scarlatina, I told you what the cold affusion is, and how it ought to be administered. The mode of application is the same in typhoid fever. I will only remark that you will not meet with that opposition to its employment on the part of the relations of the patient, which is so often encountered in cases of scarlatina and other eruptive fevers. They have no dread of an imaginary driving in of the eruption, and consequently you are left much freer in your movements. If circumstances prevent your using the cold affusion, you may have recourse to cooling lotions, such as bathing the skin with vinegar and water. Tepid baths, particularly at the beginning of the disease, are of undoubted benefit: the patient may remain in the bath as long as he can bear it. I will now go back to the subject of malignity, that I may point out the DOTHINENTERIA. 267 differences between it and ataxia. Malignity, as I have already said, is a kind of ataxia, but it is an ataxia of those organic functions the regular and continuous exercise of which is indispensable to life. Here, the morbific cause having struck directly in its essence the force presiding over vital functions, the correlation of which is broken, and there is not only collapse as in ady- namia, but annihilation, existence being threatened with an immediate and insidious termination. The older physicians perfectly understood these differences, recognizing a true, primitive, protopathic malignity, declaring itself all at once at the beginning of the disease, and a secondary, deutero- pathic malignity supervening at a later stage. You cannot do better, in relation to this subject, than to read the aphorisms of Stoll on febrile de- bility and malignity. Malignity arises in two very distinct ways. It may be dependent on causes in themselves injurious to life, such as mental emotions, depressing passions, and vegetable or animal septic poisons, to which probably belong the morbific principles which engender epidemic, endemic, and contagious diseases-principles which vary in their activity according to the epidemic, and according to the nature of certain unknown influences. At other times, the conditions which give rise to malignity belong exclusively to the individual. Those which are known generally depend upon impaired vital energy arising from prolonged excess of any kind, or upon excessive san- guineous or other discharges consequent upon previous diseases. Any morbid cause taking the economy by surprise when under such conditions, may bring on maladies which will assume the character of malignity. The characteristic signs of malignity are the occurrence of symptoms having no apparent relation to the nature of the disease, the constitution or temperament of the patient, or the ordinary influence of external or in- ternal modifying causes; and great anomalies in the symptoms, for ex- ample, the exclusive predominance and confused mixture of some symp- toms, such as very high temperature associated with very feeble pulse-the alteration of symptoms, such as extreme cold succeeding burning heat- the moderation and apparent regularity of the symptoms during the first period of the disease, and their fatal severity at a more advanced stage, without any apparent or adequate cause. Other signs of malignity are sudden debility, disorder of the circulation, irregularity of the pulse, great acceleration of the respiratory movements; also, great dyspnoea, of which the patient makes no complaint, and which is neither explained by auscul- tation during life, nor by examination of the thoracic organs after death. This malignity is met with in every species of fever, in intermittents (then called " pernicious"), and in eruptive and non-eruptive continued fevers. Thus we have seen malignity in scarlatina, measles, and small- pox ; but malignity is more commonly met with in typhoid fever, in combination with its simple, adynamic, and ataxic forms, and constituting a variety of the disease, which has been erroneously regarded as a distinct species, and designated " malignant fever." Parotitis and Deafness as Prognostic Signs of Dothinenteria. Gentlemen, such of you as have attended my clinical wards for some years, must have seen patients affected with parotitis at the termination of doth inenteric attacks. Very recently, you may have observed this occur- rence in a young man of twenty, in St. Agnes's Ward. This is what the old physicians would have called a crisis or metastasis; but I call it a very evil-boding complication. The significance of parotitis is very differently 268 DOTHINENTERIA. regarded ; some look on it as always a serious complication, while others con- sider its appearance as an announcement of the favorable termination of the disease. For my part, gentlemen, I regard parotitis as a very formid- able complication ; it is an affection from which I have almost never seen dothinenteric or other fever patients recover. It is not so with deafness, in respect of which, however, differences have to be established. When the deafness is only on one side, the prognosis ought to be guarded: there is reason to fear a lesion of the organ of hear- ing, and suppuration often supervenes, resulting it may be from simple catarrh of the mucous membrane of the external auditory canal, or-and then the case is more serious-in an alteration in the petrous portion of the temporal bone, which leads to affections of the brain. I saw an example of this in a woman who died from an affection of this kind, developed spon- taneously and without antecedent typhoid fever; at the autopsy we found, as you will recollect, inflammation at the base of the brain. When the deafness occurs on both sides, I generally look on the prognosis as favor- able ; I have often called your attention to this point, stating that I have almost never seen persons die from dothinenteria who had been deaf on both sides during the course of the disease. In these cases, I look on the deaf- ness as depending upon the propagation of the catarrh to the Eustachian tubes. I do not say that the deafness is the cause of these patients recover- ing ; but simply that I have rarely seen dothinenteric patients die who had been deaf on both sides. Without being able to explain this clinical fact any better than those who have stated it before me, I state it to you, and ask you to verify it in your practice. Dothinenteria may at first Simulate Intermittent Fever; and Marsh mittent] Fever may likexvise at the beginning of the attack Simulate Doth- inenteria. Gentlemen, there is in bed No. 29 bis of our St. Bernard Ward a woman twenty-eight years of age, ill of dothinenteria, whose case up to the fifteenth day presented peculiarities which I must point out to you. This woman has been resident in Paris for the last four years and a half, and up to her present illness, has always enjoyed good health. One day, without any known cause, she had a feeling of a sort of feebleness. Next day, she sat down as usual to her needlework, going to the shop where she worked, although she experienced a certain degree of discomfort, and had less appetite than usual. She tried to eat, but digestion was difficult. This condition continued for five days, and was accompanied by weariness and pains in the limbs, some pain in the loins, nausea, several fits of vomiting, and a very constipated state of the bowels. She stated that once in two days, she had had, about four o'clock in the afternoon, an attack of shiver- ing followed by heat and then by sweating; and she informed us that these paroxysms of fever soon came on every day, assuming a double tertian type, a fact which she indicated by mentioning that they were more violent one day than, another. She was a native of Champagne ; and had never had intermittent fever. When she entered the Hotel-Dieu, on the 11 th June, she stated that she had been so ill since the 4th as to be obliged to keep her bed, and discontinue her occupations. When I saw her for the first time, she had very moderate fever, but on the previous afternoon the fever had been very high ; and every evening it returned. There was enlargement of the spleen, which extended several finger-breadths beyond the false ribs. There was obstinate constipation. DOTHINENTERIA. 269 The day after the patient's arrival, a mild purgative was prescribed. On the third day, the fever was continuous. There was no diarrhoea, but the tongue was red, clammy, and coated with a thin dirty fur. On the fourth day-the sixteenth from the beginning of the disease-we found rosy len- ticular spots on the abdomen, and one of the same spots afterwards appeared on the face. This fever, which began as an intermittent, at first tertian and then double tertian, became remittent and then continued, and was in point of fact an exceedingly well-marked case of dothinenteria. There*is no novelty, gentlemen, in this case. Those who have read the writings of physicians of past ages know that those great masters of the healing art were struck with similar cases, which you will find recorded in the works of Sydenham, Morton, Huxham, Van Swieten, Stoll, and many others. While they pointed them out, however, they did not explain them as I do: they saw in them a transformation of intermittent into putrid con- tinued fever, produced under the influence of bad diet, and bad treatment, when, for example, cinchona had been given too soon, in too great quan- tity, or for too long a time. Now, as I pointed out to you, when speaking of intestinal catarrh, in particular circumstances, whilst one morbid cause is acting upon an individual, and has already affected him with a disease, a new malady may supervene and place its stamp upon that which previously existed; but this is not transformation, and, correctly speaking, there is no such thing as a real transformation of one disease into another. We can in this way understand the mistake of those illustrious practi- tioners of whom, in spite of their errors, we must say what Fontaine said of the poets : " We cannot go in advance of the ancients: they have left us only the glory of following them well." In point of fact, gentlemen, the great masters of whom I speak-less informed than the moderns in the detailed information furnished by pathological anatomy, ignorant of means of investigation which we possess, such as auscultation, brought all at once to a very high degree of perfection by Laennec its inventor-the Sydenhams, the Van Swietens, the Stolls, and a host of others, inspecting nature with scrupulous attention, knew the patient better than we know him, though we know better how to make the diagnosis of the lesion. Read the magnifi- cent descriptions which they have given us; and when they refer to diseases of which all the manifestations were accessible to their observation, I doubt whether you will find in modern authors anything to compare to them. Even when some features are wanting in the picture, still, with what vigor is the sketch drawn ! Guided alone, however, by the phenomena which they observed with marvellous sagacity, they could not avoid falling, and in point of fact did fall, into inevitable errors. Thus, with respect to typhoid fever, which they saw presenting itself with very different symptoms, they found themselves under the necessity of making as many species as there are forms of the disease: they were unable to gather them up into one bundle, which Bre- tonneau accomplished when he discovered that whatever other symptoms might be present in typhoid fever, there was one lesion which was charac- teristic and constantly met with. If our -early predecessors had found the specific intestinal eruption, they would have had, like us, their testing sign to distinguish the disease in a precise and positive manner; they would have avoided confusion; they would no more have mistaken dothinenteria under its different aspects, than they would have mistaken small-pox, scar- latina, or measles. But since their day, how many steps has it taken to arrive at the truth ! Prost, in his work, published in 1804, entitled "La Medecine Eclairee par I' Ouverture des Corps," was first: he described, upon the whole, very well, 270 DOTHINENTERIA. some of the alterations of tissue peculiar to dothinenteria, the ulcerations which he met with being in his opinion the last stage of a phlogosis, of which the first stage was redness: afterwards, finding this redness in the intestines of all persons dying from different diseases, provided they were not anaemic, he concluded that intestinal inflammation was almost always the cause of death, a false notion, which at a later period was taken up by Broussais, and gave birth to the celebrated doctrine of the Val-de-Grace, entirely founded on a heresy in pathological anatomy. Seven years after the treatise of Prost, MM. Petit and Serres wrote their work-"fTraite de la Fievre Entero-mesenteriquethey advanced a little nearer to a concep- tion of the truth, by establishing the specific character of the intestinal lesion, which they vary justly compared to small-pox or cow-pox; but they were still far from grasping the true bearing of the facts, for, not realizing what was due to the progress of the eruption, and not perceiving that the lesion varies in appearance according to the stage of the disease, they recog- nized three varieties of the fever, viz., the simple, the papular, and the ulcerous. Then came the remarkable labors of Bretonneau, which shed a perfectly new light upon the history of fevers, and by using which no one in the present day can be deceived. Dothinenteria being in the present day characterized in an exact manner, we have nothing to do with the transmutations which our predecessors were in the habit of pointing out: we no longer see intermittent fevers change into putrid fevers, though we observe that under certain circumstances the latter at their commencement assume the aspect of the former. It often happens that, on interrogating and attentively examining the patient, we find a more or less conspicuous group of symptoms not met with in marsh fevers, and commonly occurring in continued putrid fevers, which put us on the way to a correct diagnosis. To such groups of symptoms belong headache, insomnia, and vertigo; also, softness of the pulse, tendency to diarrhoea, and gurgling in the right iliac fossa, brought on by pressure over the part. Besides, after the first paroxysms, the type itself of the fever assists in clearing up the nature of the case. The further we are from the onset of the disease, the shorter is the interval between the paroxysms: at first there is a paroxysm of fever once in two days, then it occurs daily, or the type becomes double tertian, as in the woman of bed No. 26 bis; then the fever in place of being intermittent is remittent, and so by degrees assumes the continued type, with which at last it is completely invested. From the beginning the case is so absolutely dothinenteric, and so removed from the nature of an intermittent transformed into a continued fever, that if the patient were to be carried off about the seventh or eighth day by an acci- dent, before the disease had become permanently invested with its own ex- ternal characters, the specific intestinal lesion would be seen at the autopsy. Enlargement of the spleen, which occurred in the case I have just de- scribed, may lead to an error in diagnosis. Splenic enlargement, which exists in nearly all cases of marsh fever, of which indeed it is the anatomical characteristic, is likewise present -in nearly all cases of dothinenteria. There is a qircumstance which may perhaps serve to distinguish the one from the other: in putrid fever there is engorgement of the spleen from the beginning of the attack, which often diminishes as the malady goes on ; whereas, in marsh fever, it is at first slight, but increases with each repetition of the febrile paroxysm, till at last it sometimes attains an extraordinary size. It is particularly in districts where marsh fevers are endemic, and in persons who have not been long absent from such localities, that we see dothinen- teria begin by showing the intermittent type. We had an example of this DOTHINENTERIA. 271 in a woman who presented at the beginning of the fever symptoms similar to those experienced by the patient who occupied bed 29 bis: she had lived for a long time in a district where intermittent fevers were always prevailing. Change in the type of a fever also occurs in an inverse order; and it is likewise in places poisoned by emanations from marshes that this is observed. A true marsh fever which has at first shown itself with the continued type, and has simulated dothinenteria, soon assumes the regular intermittent type, and, as the case advances, becomes tertian, double tertian, or quartan. The term "intermittent" cannot, therefore, be reserved, as is usually the case, to designate only one species of fever, the phenomenon of intermitting being a very variable sign, and one met with in every kind of fever, as I have just said. Consequently, I think we ought to substitute for the term "intermittent" fever, the term "marsh" or "palustral" fever. Now marsh fever is just as incapable of being transformed into dothinenteria as is dothin- enteria of being transformed into marsh fever; but it is quite necessary to know that changes of type take place. A case of marsh fever, which at the beginning was a strongly-marked intermittent, may become continued, though this is not a frequent occurrence; just as a marsh fever may at first be continued, and soon assume in a well-marked manner its own intermit- tent type. Cases collected in the French possessions of Africa (where our military physicians have elucidated this important question), have conclu- sively shown that marsh fevers undergo these changes of type. Science and art are particularly indebted to Dr. Boudin for having cleared up this point in nosology better than any one who preceded him.* The malady, then, does not change its nature when it undergoes change of type: under all its different forms it remains the same marsh fever; and the proof of this is that it is always as necessary in treating it to have recourse to cin- chona (or its substitutes, such as the arsenical preparations lauded by Bou- din), when intermittents become remittent, as in those which are continued before they assume their ordinary type. If, then, gentlemen, you are practicing in a district where marsh fevers are not endemic, do not be too confident as to the character of the inter- mittents you meet with, when they are not quartans nor well-marked ter- tians : be distrustful of them when they are double tertians, but particu- larly when they are quotidians. Before administering cinchona or sulphate of quinine, wait, and observe whether the type is not going to change : it may not be long till you see the intervals between the paroxysms become shorter and shorter, and the paroxysms become less and less paroxysmal, so that, for example, if during the first three or four days the rigors con- tinued for an hour accompanied by chattering of the teeth and great dis- comfort, by the fifth, sixth, or seventh day, they will not last more than half an hour, and by the eighth or ninth day they will be quite transient. But whilst the paroxysm becomes less defined, its duration becomes longer every day, the continued form of fever becomes more and more decided, and very soon dothinenteria is fully characterized. On the other hand, if you are practicing in a locality where marsh fevers generally prevail, do not be in a hurry to begin the treatment of a malady which, though it commenced with the symptoms of continued fever, may present the parox- ysms of a remittent at the end of four or five days. You will probably soon see the fever assume a well-marked paroxysmal character. Though the manner in which the old physicians interpreted the facts was erroneous, the facts themselves were not the less real; and they were * Boudin : Traitedes Fievres Intermittentes, 1842 ; Traite de Geographic Medi- cale. Paris, 1857, t. ii, p. 530. 272 D0TIIINENTER1 A. right, when, following the precept of Hippocrates, they refrained from in- terfering with an intermittent till after the seventh paroxysm. By acting thus, you will avoid the risk of being led to believe that you have reduced an incipient dothinenteria to the proportions of a regular intermittent fever which can be easily cut short by cinchona, when in reality you have only had to do with a marsh fever which had at first the continued type. On the other hand, if you have a case of mild synocha, such as is so common at Paris, which in the beginning of the attack assumes the intermittent type, and in general terminates spontaneously in recovery, you will not make the mistake of supposing that you have cured a real intermittent fever, whether it be with cinchona or the sulphate of quinine, or with pre- tended febrifuges, such as the bark of the horse-chestnut, table-salt, &c., recently extolled, and which owe their apparently successful results to the fact of their having been administered in cases similar to those of which I am now speaking. Finally, when you perceive that you have to do with a case of dothinenteria, exhibiting at the outset the phenomena of inter- mittent fever, you will not have to take blame to yourself for having had recourse to unsuitable treatment, nor will you accuse cinchona of having changed a fever which is not generally serious into a formidable disease. Contagion.- Conditions under which Dothinenteria occurs. Opinions, gentlemen, are still divided on the question of the contagious- ness of dothinenteria, but the number of the disbelievers in contagion is daily diminishing. We cannot attain the solution of so complex a prob- lem in Paris, where, as in all large cities, we want the information neces- sary to enable us to trace cases up to their origin. The question has, how- ever, been answered by physicians practicing in small places, where it is easy to know the patient who was first seized. It is therefore to physicians who are so situated that the question has to be put. On examining the reports annually received by the Academy upon epi- demics prevailing in the departments, one becomes convinced that the con- tagious character of typhoid fever is among the ascertained facts of science. So far back as 1829, the fact was announced by Bretonneau, by Gendron of Chateau-du-Loir, and by Leuret: it was repeatedly confirmed by Le- tanelet, Lombard, Mayer, and Thirial, and more recently by Piedvache, Letenneur, Ragaine of Mortagne, and many others. Without seeking to accumulate further proofs in support of my proposi- tion, I will confine myself to making you acquainted with some character- istic facts, which have already been placed before the Academy in the report I was commissioned to present on the epidemics which prevailed in France in 1857. By quoting exactly the narrative of the observers them- selves, we shall be better enabled to see the degree in which the term con- tagion is applicable to the transmission of dothinenteria. The importation of the disease into the locality where it is spreading, by an inhabitant who has contracted it elsewhere, can almost always be made out, if the circum- stances are carefully inquired into. When the malady is once installed, its propagation goes on by a series of transmissions, which are sometimes very easy, and at other times impossible, to follow. At Maylargues, in the department of Lot, according to the report of Dr. Mayneur, there arrived, about the end of November, 1856, a soldier, dis- charged from the army of Africa: a month afterwards, he died of typhoid fever. Towards the close of his illness, a woman, a neighbor who had at- tended upon him with the most careful assiduity, took the same disease, and DOTHINENTERIA. 273 died. A brother of the soldier, aged sixteen, also died of it on the 6th of March. Two of his sisters, in the same month, contracted the disease suc- cessively, and recovered after tedious convalescence. The female neighbor whom I have mentioned communicated the disease to a son, aged seven- teen, who died on the 22d of May. In a short time after this, the fever struck down so many people that it became impossible to follow its progress. Dr. Moussillac states that typhoid fever was imported to Carriol (Gironde) by a young workman, a cooper, who came home sick to his relations. The family, consisting of seven individuals, lived in a large, well-ventilated house: they all took the disease in a severe form, and three of them died of it. The disease radiated from that centre, showing itself in persons in communication with those affected; and the persons so contracting it, by removing to other and sometimes distant localities, took it with them to places where it had not previously appeared. The epidemic of the arrondissement of Ambert (Puy-de-Dome), observed by Dr. Mavel, seems to have originated in a manufactory. The house- servant fell ill on the 11th January ; he was taken to his home, in a village distant two kilometres, where he was attended by his wife: he recovered. His wife took the fever, and died. A sister-in-law and an uncle, both of whom had waited on him, contracted the disease, and died of it. Soon afterwards, every house in the village had cases of typhoid fever. A woman, who was cook in the factory, and her sister, who was a workwoman there, upon feeling the first symptoms of the disease, were taken home to their family, a distance of five kilometres: one died, and the other recovered. The malady soon spread in their village ; and one of the villagers who took the disease, having been removed to his home at a little distance, marked by his arrival the beginning of the epidemic in that place. On the 31st May, 1857, says Dr. Fourrier, I was called to Audon-le- Romain (Moselle), to a young man of twenty, who had arrived from Paris,, where he had been unwell for some days. He had all the symptoms of typhoid fever, and the intestinal affection was very acute. Companions who came to see him were, after him, my first patients; and subsequently,, his father, brother, and two sisters were successively struck down by the disease. So long as field-work kept the inhabitants of Audon away from their dwellings, the fever, though scattered about in the village, remained limited to a small number of individuals; but when harvest was finished, and the people remained constantly with the sick, a general infection of the community took place, and at one time, among the 442 inhabitants, there were 40 cases. A workman of Anderny went to work at Audon during August; he there contracted the disease, and on his return home gave it to his wife and father-in-law. Up to his return there had been no cases of typhoid fever in Anderny. A man, aged sixty, went on business to Audon, and notwithstanding his advanced age, took typhoid fever on returning to the village where he resided. When he had been ill for fifteen days, his son, aged twenty, took the disease, and soon afterwards two daughters, aged respectively seventeen and thirteen. If, adds Dr. Fourrier, people are so skeptical as to see nothing but coincidence in all this, I ask, wherein will they see the relation of cause to effect? Dr. Reignier mentions the following circumstances: On the 29th July, 1855, a girl, aged twenty-four, called Theobald (de Trombern), experienced the first symptoms of an attack stated by a physician to be typhoid fever. The Theobald family was in easy circumstances in the village; the most assiduous cares were adopted with a view to overcome the disease; and at the end of six weeks the patient was re-established in health. This re- mained an isolated case for eight days : a second case then occurred in the VOL. I.-18 274 DOTHINENTERIA. next house: some days later there were new cases in another house; but none of the persons affected had had any communication with the girl Theobald. The contagious character of the epidemic afterwards became well marked. It is worthy of notice that the earliest case of the disease, occurred in the first house of the village on the northeastern side, and that the subsequent cases appeared in order of succession from house to house, till the opposite or southwestern extremity was reached. A boy, twelve years of age, cowherd to the mayor of Bievres (Aisne), whose wife and daughters successively had had typhoid fever, contracted it, and brought it with him to his village, Orgeval, distant three kilometres, and where there had been no case of the kind. He there communicated it to a female relation who waited on him, and she gave it to another female relative who came from the other end of the village to assist her. From that time, typhoid fever spread in the village. Nor was that all: a young man, employed as a servant in the house at Orgeval, took the disease, was sent to his home, a distance of six kilometres, whither he carried the dis- ease, which became epidemic in the place. This case and others of the same kind are mentioned by Dr. Pierme, a resident practitioner, under whose observation«they occurred. At Chamouille, in the same department, Dr. Guipon, who observed the disease with scrupulous exactitude from the beginning of its outbreak, has published an account of the epidemic accompanied by an ingeniously ex- pressive little map of the localities. A young man, Louis Meurice, took typhoid fever, without any known cause, between the 26th June and the 13th July, 1857. His aunt, living at Bertrand's Mill, two kilometres from Chamouille, brought the disease into her house, where her husband and three children took it in succession between the end of July and the 1st October. The woman died; and on her death one of the sick children was taken to Chamouille, to the house of a woman called Millepas, forty-five years of age, who after attending on the child, took the fever, and was under treatment from the 15th September to the 1st October. Eight days after- wards, a woman, her neighbor, took to her bed. On the 17th September, a woman of the name of Deguay, aged forty, who had attended upon the patients at the mill, contracted the fever, and suffered under it from the 17th October to the 3d November. Two months after its first appearance in Chamouille, the fever became epidemic there. In a population of 224, there were 27 attacked. Similar facts were observed in the epidemics of 1856. Typhoid fever was carried to a hamlet in the department of Loir-et-Cher, by a young man who went there to be attended upon by his family. His father and mother, two brothers, a sister, and the house-servant, all of whom were almost con- stantly with him, contracted the disease: the sister and the servant died. The young man, who was a servant at Pont-Levoy, was succeeded in his service by a person who was lodged in the room which his predecessor had left: in a short time he also took the disease. M. Yvonneau, who gives these details, traced out with praiseworthy care the history of the spread of the fever within these narrow limits of the epidemic, and the documents which he has furnished on the subject may be profitably consulted. At Paris even, unexceptionable facts of the same description have been pointed out; and one was recently communicated to me by Dr. Firmin, under whose observation it came. M. de G., aged twenty-four, employed in the service of the Western Railway, took fever at Batignolles. He was removed to his brother's house in the Rue Suresnes, where he was waited upon by his mother, who was recalled to Paris, after an absence of two months, to attend upon him. On the twenty-second day, this lady felt the DOTHINENTERIA. 275 pains, lassitude, and prostration characteristic of the beginning of the fever, and she very soon had all the symptoms of thoroughly confirmed dothinen- teria. From the examples I have now given, the contagious nature of dothinen- teria is incontestable. When in opposition to these positive facts, negative facts are adduced, and an exaggerated importance is assigned to them: when we are asked to explain why it is so rare to see persons contract the disease in our hospital wards from the patients who have it; when we are referred for example to the statement that of 439 cases observed at the Hotel-Dieu by Chomel and Louis only 10 began in the hospital-we men- tion, among other possible explanations, that the individuals who thus escaped may at some former time have had the disease. An explanation of a more general character consists in the admission which must perhaps be made, that the energy of the contagium is less when cases are only occur- ring sporadically, than when typhoid fever is prevailing as an epidemic. As it is frequently impossible, notwithstanding the most painstaking re- searches, to discover the origin of the contagion, and as it is obvious that typhoid fever at some time or another had a beginning, we cannot refuse to admit the possibility of its arising spontaneously, although we hold that it is a contagious disease. Let us see then under what conditions it is devel- oped. Some of the conditions must be sought in the individual himself, and others external to him. The first are the exciting causes, the chief of which is contagion; the second are the predisposing causes. Both classes of causes are difficult of recognition. Were I to discuss the influence of an atmosphere vitiated by putrid emanations, the influence of spoiled articles of food and contaminated drinks, I should be occupying your time with trivialities, because these are nothing more than hypothetical causes. I will pass over these topics as well as the influence of mental emotions, ex- cessive fatigue, constitution, temperament, which have great importance in the opinion of many, and briefly consider the influence of age, overcrowding, and acclimatization. Dothinenteria is a disease of adolescence and youth. However, it is not so unusual as was long supposed for it to attack children, and even those of a very early age. At Paris, and in other places where the disease is endemic, it is very frequently met with in childhood: there are cases men- tioned in which it occurred in children between two and seven months: and the nearer we come to the age of puberty, the more common is doth- inenteria. In my own family, my daughter's three children had it. The disease is generally milder before than after puberty: still, even in child- hood the disease often terminates fatally, and I lately saw a little girl of five and a half die of it after having been ill for little more than twenty days. Between the ages of eight and fourteen, dothinenteria becomes more common : and it is between the ages of fourteen and thirty that per- sons usually contract typhoid fever. You have remarked that in the dif- ferent epidemics of which I have been speaking, cases were mentioned in which the patients were forty and forty-five years of age: you recollect the case of a woman of sixty-four, who died of intestinal hemorrhage, and at whose autopsy we found doth inenteric ulceration. MM. Lombard and Fauconnet of Geneva have recorded similar ages of typhoid fever patients, and they even mention a case which proved fatal in a man of seventy, at whose autopsy they found the characteristic lesions of the Peyerian patches. Dothinenteria, then, does not spare old people, though it is not a common disease in advanced life. If overcrowding does not of itself engender the disease, it is at least a powerful auxiliary in producing it, as it favors contagion, increases the 276 DOTHINENTERIA. severity of the attack, and is even the cause of its assuming the most deadly epidemic character. In respect of acclimatization, you have had an opportunity in our own patients of verifying a fact to which the attention of physicians has long been directed, viz., that persons coming to Paris from the provinces are very often attacked with typhoid fever soon after their arrival. In the cases registered during the first six months of this year, you will see it noted that a very small number of our patients belonged to Paris, and that those who did, had lived in it only for periods of seven years, six years, four years, two years, eight months, five months, and two months. But if we bear in mind that what is observed in dothinenteria is likewise observed in small-pox and scarlatina, we shall be less inclined to consider non-acclimatization as a predisposing cause. We shall recollect that among the numerous young persons of both sexes who ceaselessly crowd to Paris, some to complete their education, the majority to pursue occupations of many kinds, the greatest number, having lived in country places where typhoid fever only prevails at occasional intervals, have not paid their tribute to the disease, and are consequently in a condition to become im- mediately subject to the influence of the contagion, which they everywhere encounter in a populous city where the disease is in permanence. I have already told you, that if adults born in Paris take the disease less frequently than new comers, it is because the former have generally had dothinenteria during childhood or early adolescence. I will conclude what I have to say on the etiology of typhoid fever by mentioning a curious fact first pointed out by Dr. Louis le Cottier, a phy- sician at Mazidres. He says that typhoid fever, within forty years, broke out as an epidemic three times among the inhabitants of the farm of Haut- Verger in the commune of Chapelle-Baton (Deux-Sevres), and upon each occasion, the outbreak occurred after the cutting down of a wood upon the outskirts of which the farmhouse is situated.* Though I cannot explain this fact, I do not consider it the less deserving of being here mentioned. Treatment of Dothinenteria.-Regimen of the Patients. Gentlemen, you observe that in a great number of cases of dothinenteria, I remain almost passive. When it follows its natural course, when the symptoms and special complications do not demand active measures, my treatment is limited to prescribing infusion of chamomile as a tisane, acid- ulated drinks such as lemonade or orangeade, and water sweetened with gooseberry or cherry syrup. The intervention of art is generally useless in the eruptive fevers, to which dothinenteria presents striking analogies. Their progress is but very slightly modified by the available resources of medicine. When the cases are mild, recovery takes place spontaneously ; and a judicious physician will avoid disturbing the curative efforts of nature by unreasonable med- dling. On the other hand, when the cases are severe, the disease often shows threatening tendencies as it advances, and then our interference may be of real benefit. But such fortunate occasions are more frequently met with in scarlatina, measles, and small-pox than in dothinenteria, yet in all of them we are most commonly obliged to recognize our impotence and submit to consequences which we cannot prevent. Indications for recourse to active treatment present themselves, however, much more frequently in dothinenteria than in the other eruptive fevers. This arises from the circumstance that dothinenteria, much less precisely * See the Union Medicale, for 5th January, 1858. DOTHINENTERIA. 277 characterized, much less distinct in its symptoms than is generally the case in scarlatina and measles, and still more in small-pox, is accompanied much oftener than they are by manifestations which, while they do not take away anything from its nature, impart to it that great diversity of form which I have pointed out, and against which we have to contend : it also arises from the various forms, even the mildest being subject to local complications of greater or less severity, which play an important part in the course of the disease. In speaking of the adynamic and ataxic forms, I stated that in the former the efforts of the physician ought to be directed to the support of the failing powers of nature, and that as the therapeutic indication is to promote reac- tion, it is necessary to have recourse to stimulants and tonics: I at the same time entered into some details. With reference to the ataxic form, I said that cold affusions were decidedly useful in moderating the excitement and irregularity of action in the nervous system. I have already explained my treatment of intestinal hemorrhage. When there is very severe bronchitis, or when there is pneumonia, I give antimonials, and I produce counter-irritation of the skin by applying a lotion of the tincture of iodine. This is a powerful counter-irritant, and one the effects of which can be regulated: it has not, moreover, the incon- veniences of a blister, which sometimes, as you know, gives rise to a gangre- nous sore. I have still to recapitulate the measures I pursue in ordinary cases, par- ticularly in respect of diet, not only the diet during the course of the dis- ease, but likewise in convalescence. I look upon dietetic management as the chief feature in the treatment, and I attribute the success which I have had in typhoid fever to the dietetic plan which I follow. So much impor- tance do I attach to dothinenteric patients having proper food, that it is by dietetic means, aided by medicines, that I endeavor to subdue the symptoms referable to the digestive canal, and to regulate its functions as much as possible. It is in this way that I moderate profuse diarrhoea, correct obsti- nate constipation, modify a saburral condition, and restore impaired appetite. When the bilious or saburral condition is very decided, you have seen me begin by giving ipecacuan as an emetic. I generally prescribe three grammes of the powder divided into three equal parts, directing one to be taken every ten minutes till vomiting is induced. This treatment not only modifies the saburral state, but likewise exercises a beneficial influence on the diarrhoea. When the stools are excessive both in number and in quantity, I usually begin by ordering a saline purgative-for example, 25 or 30 grammes of the sulphate of soda, or of the tartrate of potash and soda, medicines which probably act beneficially by modifying the intestinal secretions. This treat- ment is particularly indicated in cases in which the diarrhoea is accompanied by a certain degree of meteorism : in such cases the saline purgative may with great advantage be repeated several times. When I do not succeed in thus obtaining the expected modification of the intestinal secretions, I prescribe what are called absorbent powders. One of these powders, con- taining 50 centigrammes of subnitrate of bismuth and an equal quantity of prepared chalk, may be given with benefit from three to eight times in the twenty-four hours, the frequency of the repetition being regulated by the severity and obstinacy of the symptoms. I also often give the English mix- ture, which I thus formulate: Prepared chalk, . . . .30 grammes. Syrup of orange-peel, . . .30 " Water, ...... 90 " 278 DOTHINENTERIA. I also frequently order the powder of columbo root in doses of 50 centi- grammes up to a gramme. Finally, when these prescriptions prove ineffec- tual, I have recourse to more energetic alteratives. I then prescribe 5 centi- grammes of nitrate of silver,* to be taken in five doses, at intervals of an hour. The following is my formula : Crystallized nitrate of silver, 5 centigrammes. Water, a quantity sufficient to dissolve the nitrate. Add to this solution enough of crumb of bread to make a mass, and then divide the mass into five pills of equal size. If, as sometimes happens, there is constipation in place of diarrhoea, I open the bowels by giving ten or fifteen grammes of castor oil, a purgative which in the circumstances is very much to be preferred to the neutral salts, the operation of which is soon over, and is succeeded by a tendency to confinement, an inconvenience which does not attend the employment of castor oil. When the constipation does not yield to castor oil, I pre- scribe 5 centigrammes of calomel in the form of pastel, and a gramme of the powder of jalap, the latter to be taken a quarter of an hour after the former. If, notwithstanding this treatment, the constipation still continue, I repeat the calomel, and in place of giving jalap after it, I give 10 grammes of senna in the form of a very concentrated infusion, mixed with infusion of roasted coffee. Generally, however, the regular evacuation of the bowels, and also the removal of meteorism when present, may be accomplished by the patient taking daily, night and morning, a lavement of infusion of chamomile. In the mucous form of dothinenteria, which is sometimes very tedious, you have seen me stimulate the appetite by administering bitters, such as the decoction of quassia, cinchona, &c., and preparations of strychnia, such as 5 centigrammes of the powder of nux vomica, or some of the bitter tincture of Baume, which derives its stimulating properties from St. Igna- tius's bean. According to the nature of the case, the patient may take one, two, or three drops of this tincture immediately before his soup. I now come to the subject of diet. Perhaps, gentlemen, it has seemed strange to you that I should insist so positively upon the necessity of giving nutriment to dothinenteric patients, not merely as most of my colleagues now do, at a somewhat advanced period of the attack, when the fever is moderate and the tongue less coated, that is to say, towards the end of the first or beginning of the second week, but from the very commencement, and during the whole course of the malady. In point of fact, I require my dothinenteric patients, from the very first, to take daily two small portions of a soup made without meat, and also some tablespoonfuls of meat broth, disregarding the repugnance to food which some patients show, and with- out being deterred even when there is vomiting, which is apparently a contraindication of feeding. In cases where there is vomiting, I advise that broths made with and without meat should be given daily in such quantities as can be borne. This practice is now recommended by a great number of the hospital physicians of Paris, as was shown by an interesting discussion on the sub- ject in the Societe de Medecine des Hopitaux, in October, 1857, in which I was asked to take part, with men whose opinion is of undoubted weight. Some of these gentlemen, my honorable professional brethren Drs. Le- groux and Barth for instance, do not allow their patients to have nourish- * Five centigrammes-that is, five hundredths of a gramme-are about five- sevenths of a British grain.-Translator. DOTHINENTERIA. 279 ing diet till about the eighth day, while Drs. Aran, Behier, and others, entertain views similar to my own, and force their dothinenteric patients to take food from the beginning of the attack. In this discussion, Dr. Cahen, judiciously appealing to the experiments of Chossat on inanition, pointed out that medical observation and physiological experiment entirely agree in showing that very low diet is injurious in diseases of long dura- tion. Chossat had indeed seen that entire abstinence caused the body to lose forty-two thousandth parts of its weight, and that death was the inevitable result when the loss amounted to four-tenths of the original weight. Mr. Cahen says that in typhoid fever we see great loss of flesh rapidly supervene, and that it even proceeds to emaciation. He asks whether it is not probable that death in these cases is less the result of the progress of the disease, than of wasting of the body having reached a point incompatible with the continuance of life. In these cases, the individual feeds upon his own body, and it is with a view to prevent this autophagy, which brings either death or very dangerous symptoms in its train ; it is to support the system in its struggle with an exhausting disease of long dura- tion, that there is a paramount necessity of vigorously prescribing suitable food. I say suitable food; for while the low diet to which patients werq con- demned when medical practice was ruled by the deplorable doctrines in vogue at the beginning of the century, while a ridiculous abstinence from food is productive of the evils which I have pointed out, care must be taken not to fall into the opposite extreme of those who are not afraid to give solid food at the beginning and during the course of continued fevers. There is a great distance in the dietetic scale between the broths and light soups which I declare to be indispensable-between the tenuis rictus as Hippocrates called that famous diet-drink, barley-water-and the minced butcher-meat which some physicians compel their unfortunate patients to swallow. " Opportunum medicamentum est opportune cibus datus," wrote Celsus; and " in alimentis medicamenta sunt," repeated Aretseus. The doctrine which I maintain is as old as medicine itself. From the time of Hippoc- rates-who devoted a book to the subject-to our own day, the great practitioners of the past have always attached much importance to dietet- ics, which they have looked on as embracing the most powerful therapeutic resources of our art. Morton says that with the assistance of food well regulated from the beginning of the attack, he has seen fevers cured by the efforts of nature, without any recourse having been necessary to the pompous arsenal of pharmacy ; while cases which at first were mild have become malignant under a repetition of copious bleedings, and the abuse of emetics and cathartics. Permit me, gentlemen, to fortify my opinions on this subject by the au- thority of Graves, a man whom I regard as the most eminent clinical teacher of our age, whom I delight to quote, whom I constantly consult, and whose work ought to be your vade-mecum. Allow me also to appeal to the authority of a man who, in our own France, has equalled the illus- trious physician of Dublin, and who has left behind him the light of a brilliant career: need I say, that I refer to Bretonueau ? These two illus- trious physicians may, to a certain extent, be said to have passed their youth in contending against the abuse of abstinence from food in fevers ; and to them is chiefly due emancipation from the yoke of prejudice im- posed on practitioners, by the school of Broussais, to the great detriment of patients. 280 DOTHINENTERIA. Allow me then, gentlemen, to translate some paragraphs of Graves upon the subject now before us : " In a disease like fever, which lasts frequently for fourteen, twenty-one, or more days, the consideration of diet and nutriment is a matter of im- portance ; and I am persuaded that this is a point on which much error has prevailed. I am convinced that the starving system has in many in- stances been carried to a dangerous excess, and that many persons have fallen victims to prolonged abstinence in feverLet us examine the results of protracted abstinence in the healthy state of the system. Take a healthy person, and deprive him of food. What is the consequence ? First, hunger, which after some time goes away, and then returns again. After two or three days, the sensation assumes a morbid character, and instead of being a simple feeling of want and a desire for food, it becomes a disordered craving attended with dragging pain in the stomach, burning thirst, and some time afterwards, epigastric tenderness, fever, and delirium. Here we have the supervention of gastric disease, and inflammation of the brain, as the results of protracted starvation." " Read the accounts of those who perished from starvation after the wreck of the Medusa and Alceste, and you will be struck with the horrible consequences of protracted hunger. You will find that most of the unhappy sufferers were raging maniacs, and exhibited symptoms of violent cerebral irritation. Now, in a person laboring under the effects of fever and pro- tracted abstinence-whose sensibilities are blunted and whose functions are deranged-it is not at all improbable that such a person, perhaps also suf- fering from delirium and stupor, will not call for food, though requiring it; and that if you do not press it on him, and give it as medicine, symp- toms like those which arise from starvation in the healthy subject may su- pervene, and you may have gastro-enteric inflammation, or cerebral disease, as the consequence of protracted abstinence. You may, perhaps, think that it is unnecessary to give food, as the patient appears to have no appetite, and does not care for it. You might as well allow the urine to accumulate in the bladder, because the patient feels no desire to pass it. You are called on to interfere where the sensibility is impaired, and the natural appetite is dormant; and you are not to permit your patient to encounter the horrible consequences of inanition, because he does not ask for nutri- ment. I never do so. After the third or fourth day of fever, I always prescribe mild nourishment, and this is steadily and perseveringly continued through the whole course of the disease." " Again, let us see how close a resemblance the symptoms generated by long-continued denial or want of food bear to those which are observed in the worst forms of typhus. Pains of the stomach, epigastric tenderness, thirst, vomiting, determination of blood to the brain, suffusion of the eyes, headache, sleeplessness, and, finally, furious delirium, are the symptoms of protracted abstinence, and to these we may add tendency to putrefaction of the animal tissues, chiefly shown by the spontaneous occurrence of gan- grene of the lungs. It has been shown by M. Guislain, physician to the hospital for the insane at Ghent, that in many instances gangrene of the lung had occurred in insane patients who have obstinately refused to take food. Out of thirteen patients who died of inanition, nine had gangrene of the lungsIt is not, therefore, wrong to suppose that when a sys- tem of rigorous abstinence has been observed in fever, and when food has been too long withheld, because, forsooth, the patient does not call for it, and because his natural sensibilities are blunted and impaired-it is not, DOTHINENTERTA. 281 I say, unreasonable to infer that gastric, cerebral, and even pulmonary symptoms may supervene, analogous to those which result from actual starvation."* Gentlemen, I require to add nothing to these true and eloquent para- graphs of Graves, who said to his pupils: " If you are at a loss for an epi- taph to inscribe on my tomb, you may use these words-He Fed Fevers."! We are not, however, prevented from inquiring into the causes of the terri- ble symptoms produced by inanition. The normal constitution of the blood is the condition under which all the processes of interstitial nutrition take place, and good nutrition is the con- dition essential to the performance of the functions assigned to the different organs. It is by alimentation that the blood is renewed; and whenever there is a deficiency from that source in the elements required for the recon- stitution of the blood, the nutritive processes are carried on at the expense of the materials of the living organism. The animal will then live upon itself; and as it will be unable to derive from its own substance all the ele- ments requisite for sanguineous renewal, the quality of the blood will forth- with become anomalous, and the organs which the blood is designed to restore, will themselves become fundamentally altered in structure. The organs being thus altered, will supply the already altered blood with ele- ments still inferior; and thus there will be established a vicious circle- the circle of autophagy as Bretonneau called it-a circle in which the disor- ganization of the blood and the tissue goes on constantly increasing, till it ultimately attains a point at which the functions, which, at first were merely disturbed, become completely deranged and disassociated, death constitut- ing the climax of this gradual destruction of the economy. The most essential part of the treatment, then, is to give nutriment. We must observe the state of the patient with respect to strength, so that we may be able to put him into a condition to resist the fever by which he is being devoured : according to the degree of weakness, and according to the supposed duration of the disease, it is necessary to give food more or less frequently, but always in small quantity, and in the liquid form. The age, temperament, and habits of the patient, ought also to be taken into consid- eration, as is remarked by Jodocus Lommius in his little tract "De curandis febribus continuis," a work several chapters of which are devoted to the consideration of the diet suitable to the different periods of the disease. Although I lay particular stress upon regular feeding in dothinenteria, although, as you have seen every day, I oblige the patient to take light soups, I also wait longer than others before I allow him to return to a more substantial diet. At the decline of the fever, some of my professional brethren, discontinuing the low diet which they had imposed up to that period, allow solid food to be taken ; but I insist at that period upon the necessity of restricting the patients to light farinaceous food, and during convalescence (even when it is fairly established), I am among those who keep them on the shortest commons. Having been careful to maintain the strength during the whole course of the malady, however long its duration may have been, I have nothing to fear in my patients from the diastrous consequences of abstinence and in- * Graves : Clinical Lectures on the Practice of Medicine. Second edition, edited by J. M. Neligan, M.D. Two volumes. Dublin: 1848 Vol. i, p. 117-119. The quotation in the text is an exact reprint from the work of Dr. Graves-not a translation of Dr. Trousseau's French version.-Translator. f Quoted at p. 253 of Dr. Murchison's work. 282 DOTIIINENTERI A. anition; and can more easily protect them from the unfavorable occurrences to which they continue liable at the very time that they suppose their re- covery to be complete. I thus avoid bringing on attacks of indigestion, which, though they .may not cause serious gastro-intestinal mischief, nor (as sometimes happens) fatal peritonitis, may nevertheless lead to relapses, or may retard restoration to health. During the convalescence of dothin- enteric patients, it is, therefore, absolutely necessary to resist their demands for food, when, as is usually the case, they have a craving appetite. There are cases, however, in which it is requisite during convalescence, to return quickly to a very substantial and very tonic kind of feeding, pro- ceeding always with extreme caution. That is the period during which occur the symptoms of which I am now going to speak, and which are most frequently met with in persons exhausted by a rigorously low diet, or by hemorrhages. Affections which occur during Convalescence.- Gastric Disturbance.- Vomit- ing.-Diarrhoea.-Nervous Symptoms.- Vertigo.-Delirium.-Impaired Mental Power.-Paralysis.-Dropsical Effusions. The convalescence from typhoid fever is sometimes interrupted by gastric disorders, which unless very carefully attended to, may deceive the phy- sician from their seeming to demand treatment the very opposite of that which they really require. I refer to vomiting and diarrhoea, both partic- ularly apt to occur in those who have been reduced by starvation. It seems as if the stomach and intestines, having forgotten how to perform their al- lotted functions, can digest nothing. The smallest quantity of liquid food, or even of tisane, is at once rejected by the mouth; and there is a notable increase in the number of the alvine evacuations. The patients are exceed- ingly weak, their circulation is languid, and their temperature is percepti- bly lowered. Not.only are the liquid ingesta vomited, but there is regurg- itation of mucous and bilious matter of a color successively varying from yellow to apple-green, bottle-green, leek-green, greenish-blue, or even pure blue. Under the belief that the powers of the stomach are inadequate, and that the symptoms are the result of gastritis, the use of every kind of food is suspended : the patient is given skimmed milk, chicken-broth, and muci- laginous drinks, which, far from calming the disorder of the functions, in- crease it. When I come to speak of dyspepsia, and its different forms, I will tell you that gastritis, regarding which so much that is erroneous has been stated, is a rare disease; and that, on the contrary, the food apparently most calculated to excite inflammation of the stomach is that which is most easily borne. I now refer to symptoms connected with the nervous system, to disorder of the function of secretioh, the best means of subduing which is to give solid food. In these cases, it is not broths and soups that one must prescribe, but grilled or roasted meat in small quantities, fermented liquors, and good old wine in moderation. In some cases, eating what are called heavy kinds of meat, such as pork, is the only means of subduing obstinate vomiting. Under the influence of this regimen, the digestive canal by de- grees recovers its tone, and soon digests as before: the vomiting stops, and the diarrhoea gradually ceases. But, gentlemen, beware of mistaking the symptoms of which I have been speaking for the relapses which occur from errors in diet. In the latter, there is real indigestion. The fever also is rekindled, the stupor recom- mences, the exanthematous spots reappear on the skin, and (as in cases which I have described to you) the dothinenteria seems to take a new start. DOTHINENTERIA. 283 In such circumstances, it would be exceedingly dangerous to insist upon feeding the patients with nutritious aliment. On the contrary, it is neces- sary for some days to subject them to a rigorous low diet-to restrict them to emollient drinks and farinaceous food ; to give chalk and bismuth ; and to wait till the storm is past, before returning to a more generous diet. Vertigo dependent on autophagy is more common than the other patho- logical phenomenon of which I have just been speaking. I will not, however, at present stop to consider it, but will reserve what I have to say regarding it till a future occasion, when I shall have to discuss the general subject of vertigo arising from disordered digestion. But delirium is, of all the nervous symptoms which demand the attention of the physician during convalescence from putrid fever, that which is most commonly met with : if its possible occurrence is not foreseen, and its cause is not attentively sought out, it may lead to the belief that there is a serious cerebral affection. We had a singular illustration of this remark in the case of a patient who occupied bed No. 16 of St. Agnes's Ward. This young man, at the twenty-ninth or thirtieth day of a putrid fever, in which he had had copious intestinal hemorrhage about the end of the second week, was convalescent, when he was seized with delirium, more continuous and more violent than he had had even when the disease was at its height. All the other symp- toms, however, were for a long time in abeyance: regular stools had suc- ceeded to the diarrhoea, and there was no longer any pulmonary catarrh: there was no fever, the pulse was only 64, and the temperature of the skin was natural. The cerebral symptoms might have led one to believe that there was a lesion of the brain similar to that observed by Piednagel in a certain num- ber of cases, a lesion consequent upon irritation or subacute inflammation of the pia mater and gray substance, and bearing some resemblance to what is sometimes met with in persons sinking under the general paralysis of the insane. My colleague of the Hotel-Dieu supposes that the delirium of the convalescence from typhoid fever is caused by the persistence of this inflam- mation, which in other respects he regards as an unimportant affection, and as not at all serious, inasmuch as it is very curable. The proposition stated in this way is far too absolute. I at once grant that the disturbance of the intellectual faculties is dependent upon an altered state of the encephalon: I admit that this alteration may be the result of congestion and inflamma- tion of which we can find traces on examining the dead body; but it is also a fact, that often no such traces are discoverable. Without giving an opinion as to the nature of this affection, it may be stated, that, be it what it may, it is an alteration produced under the influence of a septic malady which produces radical changes in the fluids, and acts specially upon the nervous system: and it may likewise be stated, that in proportion to the length of time during which this influence operates upon the economy, is the duration of the period required for a return to a normal condition. But disturbance of the intellectual faculties may also arise from the individual having been exhausted by great loss of blood, or by starving; the brain under such circumstances being deprived of its natural excitant, the blood. Now, the organ of the intellectual faculties will be longer in resuming its original activity, in proportion to the longer or shorter duration of the state of feebleness, exactly as is the case with tbe muscles, which, when they have been inactive for a long time, do not all at once regain their power. And possibly, this state of feebleness, or cerebral atony, is the most common cause of the symptoms of which I have been speaking. To sum up: If the delirium and vertigo which supervene during con- 284 DOTHINENTERIA. valescence from typhoid fever, and that hebetude which the patients retain for even from five to ten months after recovery, and which some never lose, are referable to a subacute inflammation of the membranes and cortical substance of the brain, there is generally no appreciable organic lesion, and the pathological phenomena seem to be dependent upon cerebral ansemia resulting from debility, and requiring to be treated by tonics and stimu- lants, exactly like muscular debility, to which I have compared it. The correctness of these views is shown by the delirium ceasing and the intel- lectual faculties returning to their normal state under the influence of gen- erous diet. You saw a patient who occupied bed No. 8 of our St. Bernard's Ward, who after remaining in a state of imbecility for six weeks after re- covery from severe putrid fever, regained simultaneously her intellectual faculties and her muscular power. In such cases, it would be a serious blunder, leading to aggravation of the symptoms, to resort to antiphlogistic treatment, from an idea that there existed inflammation or congestion. In a case similar to that of the woman in St. Bernard's Ward-the case of the man who occupied bed No. 16 of St. Bernard's Ward-you saw me prescribe stimulants and tonics, wine and coffee, as well as solid sustaining food. Typhoid fever is not the only disease which is succeeded by disorder of the intellectual faculties: it occurs after all septic diseases-after small- pox, scarlatina and diphtheria-and it is always by the same kind of treat- ment that the cure has to be brought about. Still, it is a cardinal point, a matter of absolute necessity, to proceed with very great caution, so as not to exceed reasonable bounds. While the diet is essentially tonic and reparative, it must be kept strictly within the limits of the digestive power: you must not go on at too great a speed from a desire to proceed without loss of time. If the quantity of food taken is in excess of the digestive capability of the individual, the gastro-intestinal symptoms will be aggravated, in place of being subdued, the vomiting will continue, and increase in severity-the diarrhoea will assume a much greater intensity, and the patient will succumb under the inveterate consequences of indigestion. The different forms of paralysis which supervene during convalescence from dothinenteria also belong to the same class of symptoms as those which we have just been considering; like vertigo, delirium, and mental debility, the different paralytic affections originate in shock of the nervous system, in organic and functional modification throughout its entire extent, caused by the morbid poison, which, having in the first instance acted directly on the nervous system, continues so to act during the whole course of the dis- ease. We can understand that the longer the duration of the malady, the more numerous will be the symptoms indicative of disturbance of the nerv- ous centres, such as stupor, prostration, impaired muscular contractility, delirium, and convulsive movements: we can understand, I say, that the more decided the adynamic or ataxic symptoms are, the more time will be required for things to return to their normal state. Putrid fevers, when the attacks are severe and protracted, often leave patients in a state of very great weakness, from which they emerge with difficulty, and which some- times continues for several months. It is likewise after these dangerous forms of dothinenteria that we meet with the paralytic affections now under consideration. The paralysis is sometimes general, affecting not only motion and sensi- bility, but also the senses, the patients being deaf and blind, as well as unable to move: sometimes also, it is localized, in which case it is generally seated in the lower extremities; at the same time implicating the bladder, DOTHINENTERI A. 285 so as to cause retention or incontinence of urine, micturition being either an overflow of the bladder, or the result of the inability of the paralyzed sphincter to retain the urine: there is also sometimes paralysis of the rectum, the patients involuntarily passing their stools. You must beware of being misled as to the nature of these cases: you will often meet with patients who seem to have this description of paralysis of the sphincters, when it really does not exist. You remember in bed No. 4 of St. Agnes's Ward, a young man who for several days soiled his personal linen and the sheets. In him, as in others, this proceeded from mental debility, or, more correctly speaking, from the laziness resulting from that debility. It is sufficient in such cases to make the patients ashamed of their dirty habits, and to threaten them with low diet in the event of their not discontinuing them: you will particularly observe cases of this kind in children. Finally, pa- ralysis may locate itself exclusively in the organs of the senses, producing a longer or shorter continuance of blindness or deafness. A restorative regimen and tonics are the only means by which we can get rid of these untoward symptoms. The diagnosis of these paralytic affections seems so simple, as to preclude the necessity of saying a word on the subject; but nevertheless, cases occur in which you might find yourselves at fault. The case of our patient in bed No. 4 is a proof that one has to distinguish between a true and apparent paralysis. The following history, communicated to me by a physician in town, will show you how much complexity there may be in this diagnosis. A girl, twelve years of age, had a serious attack of putrid fever: during convalescence, she was absolutely unable to walk. Her physician having recommended exercise in the open air, she was taken out in a little carriage, but as no improvement occurred under this treatment, she was sent into the country. No amendment had taken place in her condition, when by mis- take, she was one day left alone locked up in her room. Great was the surprise of her attendants, when, on their return, they found the door open, and the patient on her feet: to liberate herself from confinement, she had walked. The relations exclaimed that a miracle had been w rought; but unfortunately, the miracle was not a complete cure, for on the following day, the paralysis returned, and at present, according to the information which I received from the attending physician, the patient is still unable to walk. In this case, gentlemen, the paralysis was certainly not a consequence of the fever: paralytic affections consequent on fevers do not terminate so sud- denly, and when they have ceased, do not so quickly return. Though I did not see the patient, I think I may say that her affection was hysterical paralysis, for paralysis is often simulated by one of those strange whims which get into the heads of that singular class of patients called hysterical. If, as an objection to this opinion, it be said that the youth of the girl hardly allows us to suppose that her case was of this class, that at her age there is unfeigned lightheartedness, while the affection condemned her to long- continued rest and prevented all participation in the games which constitute so large a part of the occupation of childhood, I reply, that hysteria is not a rare disease, even in children of twelve years of age. In cases of this kind, we must have recourse to moral more than to what are considered strictly medical means of cure. I have recently been studying, in a convalescent dothinenteric patient, a form of paralysis which may occur as a sequel to any severe disease, but which is most frequently observed after fevers. It is the consequence of the disease itself-of its duration and severity. There is in small-pox, as you know, a form of paralysis, which, on the contrary, is a concomitant of 286 DOTHINENTERIA. the rachialgia, of the invasion-period of the disease. This form of paralysis, occurring at the beginning of a fever, is a very important element in the diagnosis: and I am not aware that it has hitherto been observed at the commencement of any pyrexia except small-pox. I have, however, just seen an occurrence of this kind in a young woman, occupying bed-No. 11 of St. Bernard's Ward, who, some days after her admission, presented all the symptoms of typhoid fever. Here, in a few words, is this case. Some years previously, the patient, on the rapid disappearance of eczema of the lower extremities, became affected with paraplegia, which continued for a whole year. She became pregnant, and from that time the paralysis gradually diminished. Her pregnancy was not attended by any serious symptoms ; but her confinement took place at the seventh mouth. For the six following years, she had very satisfactory health, till eight days before she came into hospital, when she complained of fever, lassitude, pains in the limbs, loss of appetite, and nausea, but no diarrhoea: she made special complaint of inability to stand. On examining the patient, I found that she moved the lower extremities very feebly, and said that they were the seat of lancinating pains: she also complained of pain in the dorsal region of the vertebral column, upon percussing or making pressure over it. I thought that there was myelitis, and that it was the cause of the rheuma- tism. There was nothing to lead me to suppose that it was a case of vario- lous paraplegia, as the patient had none of the symptoms of the invasion- period of small-pox, and had had the paraplegia for eight days when I saw her. There was neither stupor nor diarrhoea, and the pulse was not bound- ing. It was, therefore, to my great surprise that three days after the patient came into our wards, that is to say, eleven days from the com- mencement of the paraplegia, I observed an eruption of rosy lenticular spots on the abdomen. The paralysis soon disappeared, and did not return in the course of the disease, nor during convalescence. The typhoid fever, which was mild, pursued its normal course, and its duration was not more than three weeks. Here, then, is an example of paraplegia occurring at the commencement of typhoid fever. It is true, certainly, that the paraplegia occurred in a subject who had previously suffered from it for a whole year: still, the case deserves to be mentioned as one of clinical importance: it is an example of the "spinal" form of the disease, more particularly described by G. Fritz, and of which I have already spoken. It is important to distinguish these forms of paralysis from that muscular debility which is always observed in convalescents from dothinenteria, and which is partly dependent on nervous exhaustion, and partly on that altera- tion of the muscular tissue which I have already described. I told you* that the contractile tissue of very many, if not of all, muscles underwent, to a greater or less extent, granular or waxy degeneration: and that some weeks are required for the absorption of the degenerated tissue, and the formation of new contractile tissue in its stead. During this period, there is necessarily great embarrassment in the muscular movements. The forms of dropsy which sometimes supervene during, and in conva- lescence from, typhoid fever, as well as in connection with all serious fevers, are symptoms of the same class as those we have just been passing under review. Like the nervous symptoms, they are all dependent upon a bad general state of the economy, upon the adynamia into which organic life has fallen, but more particularly upon the special alteration of the blood, which singularly favors serous effusion into the cellular tissue and serous * See page 249, et seq. DOTHINENTERIA. 287 cavities. When we recollect the frequency with which albuminuria is met with in the course of typhoid fever, one might be induced to believe that the dropsies of which I am now speaking were associated with an albu- minuria symptomatic of disease of the kidney. But the albuminuria met with is either quite transient and purely functional, in no way connected with any real or permanent change of structure in the kidney, or it is coin- cident with the renal lesion characteristic of Bright's disease, as in cases observed by Bayer, Barthez, and Rilliet, Christison, Gregory, and others. But in the consecutive dropsies of typhoid fever, no trace of albumen is found in the urine. A fact, not less remarkable, to which the attention of physicians has been called by that laborious observer, Dr. Leudet of Rouen* is, that the dropsies consecutive to dothinenteria occui' much more frequently in some localities than in others, and that the influence of the prevailing medical constitution has something to do with their production. At Paris, for ex- ample, we rarely see them, while foreign physicians meet with them fre- quently, and describe them with great minuteness. During ten years which Dr. Leudet studied in the hospitals of Paris, and was constantly in the habit of taking down the particulars of numerous cases of typhoid fever, he never once saw dropsy following that disease, but after having been for a much shorter period a physician to the Hotel-Dieu of Rouen he there collected eight examples. These dropsical effusions, occupying almost exclusively the subcutaneous cellular tissue, are generally limited to the lower extremities, where the oedema is greatest on the most depending parts, around the malleoli, and on the posterior aspect of the feet, and posterior aspect of the thighs. But sometimes there are partial effusions into the subcutaneous cellular tissue of the upper extremities: and sometimes also, there is oedema of the face, limited occasionally to one side, as in a case recorded by Virchow, in which it was associated with obliteration of the internal jugular vein. Ascites sometimes occurs. Finally, the anasarca may be general: either appear- ing simultaneously in the different parts of the body, or being at first local- ized, and then spreading. The oedema is generally moderate in degree: in exceptional cases it is considerable, and may be compared to that which supervenes when there is organic disease of the heart. It bears no relation to the severity of the dothinenteria; and causes of debility, such as profuse evacuations and in- testinal hemorrhages, do not seem to have any effect in producing it. Trans- itions from heat to cold, which are such marked causes of scarlatinous ana- sarca, do not here seem to possess a similar influence. Though the appearance of the dropsical affections which come on pas- sively towards the second or third week of the fever, without any initiatory symptoms, is sometimes coincident with a febrile exacerbation, a copious eruption of sudamina, or an acute bronchitis, they generally disappear in fifteen or twenty days. When they continue long, they retard convalescence, but in other respects are not serious. They yield to dietetic management, and a purely tonic treatment, demanded by the state of general debility under which they have arisen. Gentlemen, the oedema of which I have been speaking is seen unassociated with albuminuria in some other pyrexise. I have often observed it in measles, and on examination the urine has generally been found to contain no albumen. But another kind of oedema which I have observed in doth- inenteria, is that which is connected with obliteration of a vein ; it is a real * Leudet: Archives Generales de Oct., 1858. 288 DOTHINENTERIA. phlegmasia alba dolens. I very recently met with a case of this kind in one of my nieces aged twenty-four. She was seized with painful oedema about the fortieth day from the beginning of the fever. Virchow's case, which I have just mentioned, is of the same description. Local Complications which supervene During and at the Decline of Dothinenteria. 1. Softening of the Cornea. A woman, suffering from a very severe form of putrid fever, was ad- mitted to bed No. 8 of St. Bernard's Ward.. During the third week, when the nervous symptoms were very severe, the eyelids were incompletely closed during sleep, leaving the inferior segment of both cornete exposed. After some days, the conjunctiva was injected, and the eyes became bleared: twenty-four hours later, there was real catarrhal ophthalmia. On carefully examining the globes of the eyes, it was easy to see that the corneae were swollen, and had a whitish, macerated appearance: there was also intense photophobia, and the patient, though in a state of stupor, complained of her eyes, even when not obliged to raise the eyelids. Her sight was very much affected. It seemed evident to me, and to all who went round with me at the visit, that the corneae were completely softened, and vision hope- lessly lost. This softening of the corneae, which, gentlemen, you have frequently' ob- served, not only in the course of dothinenteria, but also in all diseases ac- companied by cerebral disturbance, is one of the most serious complications; and one of which I was for a long time unable to understand the mechanism. I have at last, I believe, found it out: and, what is more important, I think I have discovered a very simple means of curing the affection. It is quite possible that others may claim along with me the honor of this little dis- covery. Should what I am about to bring under your notice in a few words have been previously observed by others, I shall in that circumstance find a cause of congratulating myself on having given my sanction to a little- known practical fact. We see, every day, our professional brethren claim- ing the honor of priority with a zeal which excites in me very little desire to follow their example. Let it be understood, then, that I will surrender, whenever it is necessary, all my rights over the treatment of softening of the cornea in bad fevers. But before telling you what my treatment is, before following out the history of the woman to whose case I have recalled your attention, I am anxious to explain to you the mechanism by which, in my opinion, soften- ing of the cornea takes place. You have often observed in putrid fevers, that patients sleep with their eyes half open: under such circumstances, it almost always happens that the globe of the eye is turned upwards, and the cornea entirely concealed. No other inconvenience results from this condition of the eyelids, except an inflammatory affection of the conjunctivae, and if this conjunctival inflamma- tion be, which I willingly admit it is, dependent upon the general state of the patient, as is the inflammation of the bronchial tubes and back part of the mouth, I cannot but also admit that it is aggravated by the inability to wink, as is seen in persons suffering from paralysis of the facial nerve. You all know that patients with paralysis of the seventh pair of nerves, being unable to shut the eye or to wink, have always more or less irritation of the mucous membrane of the eye; and in some cases, this irritation proceeds to inflam- DOTIIINENTERIA. 289 mation, and even to softening of the cornea. The patients themselves know how to ward off these consequences, by moving their eyelids with the assistance of the finger sufficiently often to supply the place of winking ; but during sleep, unless they take special precautions, the globe of the eye is left exposed to the air, and in the morning they awake with irritative congestion, pain, and blearedness of the eye. In all severe fevers, the eyes remain partially open, and if the stupor continue sufficiently long, or be excessive, they are night and day in the condition similar to that of persons affected with paralysis of the seventh pair. Recollect also the fact, that in putrid fevers the sensibility is blunted, and that the irritation caused by the contact of the air with the conjunc- tiva is not felt, so that the necessity for winking is not experienced. The same thing takes places with the eye which occurs in respect of the nostrils, which become filled with dust and other foreign bodies floating in the air, because, from the parts not being sensitive to the presence of foreign bodies, the patient does nothing to get rid of them. Reflect for a moment on the theory of winking, and you will perceive the reason of the frequency of the symptoms of which I have been speak- ing. There are three pairs of nerves concerned in winking. In the first place, there is the fifth pair-the sensitive pair-which transmits to the brain the impression of pain caused by continuous contact of the air, and drying of the cornea-the impression which imparts the necessity of wink- ing. In the second place, there is the seventh pair-a motor pair-which conveys to the sphincter of the eyelids the command to wink. Finally, there is the third pair of nerves-also a motor pair-which sends a branch to the levator palpebrce, and which consequently presides over the elevation of the upper eyelid. But there is still another nerve which I have to men- tion, and that is the lachrymal, which comes from the ophthalmic branch of the fifth pair, and presides over the secretion of the tears, which serve more than the ocular mucus to accomplish the ultimate object of winking,- lubrication of the conjunctiva. You can now understand that the performance of an act so complicated as that of winking, an act which requires the agency of so many nerves, should be disturbed, or even suspended, during such a disease as dothinen- teria, which in so high a degree impairs the action of the whole nervous system. You must also bear in mind that in severe fevers, there are other special conditions quite independent of the causes (to a certain extent physical) of which I have been speaking. In virtue of causes, very imperfectly under- stood, but essentially connected with the nature of septic diseases, the mu- cous membranes become the seat of congestions, which may be somewhat active or somewhat passive, and which easily proceed to inflammation and even to sphacelus. In the ordinary train of symptoms in septic fevers, we also meet with ophthalmia, coryza, sore throat and laryngitis, and in- flammatory affections of the genitals of young girls, upon which latter class of affections I shall afterwards have to make some special remarks. You will then better understand how inflammation of the cornea, caused by absence of winking, easily passes into a state of softening, which is really a kind of gangrene. Let us now revert to the clinical facts. Along with Dr. Grenat, I attended a young man suffering from a ner- vous disease, which was deficient in distinctive characters, but presented symptoms indicating that it was a connecting link between brain fever and putrid or common typhoid fever. There was slight congestion of the con- VOL. I.-19 290 DOTHINENTERIA. junctiva, arising as much from the fever itself as from the want of wink- ing. One of the cornese became softened, and the patient lost the eye. This unfortunate occurrence having made me reflect, it occurred to me that if the greatest part of the evil originated in the fever, the constant exposure of the eye to the air from want of power to wink was an im- portant, and perhaps the principal, cause of the ultimate mischief. I forthwith took steps to be able to accomplish that which in point of fact I afterwards put in practice with great success in our patient of No. 8 St. Bernard's Ward. It seemed to me, as well as to those who were present at my clinical visits when I examined this case, that the woman must inevitably lose her sight. To me the case appeared as hopeless as it appeared to others; but I never- theless resolved to try the plan which I had settled in my owm mind was the proper treatment. Having completely closed the eyelids of the patient, I placed on them two pledgets of soft cotton, which I kept in their places by means of a moderately tight bandage. This little apparatus was ar- ranged at the morning visit. During the day, the pain was less severe, and it altogether disappeared during the night. When I examined the state of matters next morning, I found to my great satisfaction that the corneae had their normal color, and excepting that the conjunctivae were a good deal bloodshot, the eyes had completely returned to their natural con- dition. There was still some imperfection of vision; but the photophobia was gone. The treatment was continued for three days, at the end of which period the apparatus was removed. The general nervous symptoms had somewhat subsided : the stupor had nearly quite disappeared; and from that time the eyes were closed during sleep. Although during convales- cence a severe attack of cholera supervened, and although that was suc- ceeded by colitis, presenting some of the characters of epidemic dysentery, there was no return of the ocular symptoms. The following case was observed by my friend and colleague Dr. Am- broise Tardieu: A man took scarlatina; and from the beginning of the attack had septic symptoms. The eyelids remained in a state of partial closure, and the lower segment of the cornea became softened, precisely as in our patient. Already, there was acute pain, photophobia, and a con- siderable affection of the sight. Suddenly, erysipelas of the face super- vened, and simultaneously took possession of both eyelids, causing com- plete occlusion of both eyes for four days. Upon the erysipelas subsiding, the patient opened his eyes, when Dr. Tardieu was very pleased to find that the eyes, which he supposed lost, were perfectly restored to their natu- ral state. Although in this case, gentlemen, the disease was not the same as that now under our consideration, the complications were identical, as were likewise the means employed to subdue them-means, however, which in Dr-. Tardieu's case, nature herself applied. The treatment consisted in the occlusion of the eyelids, a measure simple and of easy application, which I beseech you not to forget. 2. Affections of the Larynx.-Necrosis of the Cartilages of the Nose.- (Edema of the Glottis supervening during Dothinenteria, and necessitating Tracheotomy. i Gentlemen, early in March, 1858, a young man of eighteen, sent to Paris by a physician of Aix, was placed in our wards, to be treated for an affec- tion of the larynx, which had necessitated tracheotomy. On admission, D0TH1NENTERIA. 291 he was still using the tracheal tube, which he could not discontinue with- out being immediately seized with violent suffocative paroxysms. The laryngeal affection was stated to have commenced eight months previously in the course of severe typhoid fever, which, according to the written statement forwarded by my colleague, had assumed the adynamic form, and had lasted for thirty days. Towards the end of the attack, the patient was seized with almost complete aphonia, which not only continued, but became aggravated at the commencement of convalescence. Respira- tion at the same time became more difficult: expiration was performed with sufficient freedom, but inspiration was laborious and accompanied by snoring and whistling sounds. There was no pain occasioned by making pressure over the larynx ; and no cedematous swelling could be detected at the upper orifice of the air-passage, by introducing the finger far back into the throat. The dyspnoea was to a certain extent intermittent, or I should rather say was remittent, for it never quite ceased, although it diminished during the day, and increased during the night in severity. The parts at the entrance of the larynx were cauterized, and two setons were inserted over the thyroid cartilage; but no benefit resulted from these measures. Eighteen days after the commencement of the laryngeal symp- toms, asphyxia being threatened, it became imperative to perform trache- otomy to save the man's life. From the date of the operation, the patient's health became completely re-established, so that he came to Paris to get rid of the tracheal fistula, which he regarded as an irksome infirmity rather than as a malady. However, on his arrival at the Hotel-Dieu, he was still complaining of some embarrassment in his respiration; but this ceased from the time of our substituting a wider tube for the tube which he had been wearing. I made several attempts to relieve him entirely from the necessity of using the tube, with a view to closing the wound in the trachea, and restor- ing entrance for the air by the upper orifice of the larynx ; but on each occasion the excitation of suffocative paroxysms showed me that the air- passages were not free. After having been six weeks in our wards the patient, discouraged, left the Hotel-Dieu, that he might apply to others from whom he had better hopes. Several of you may remember a case similar to, if not identical with, that now narrated, which came under our observation during last year. In it, however, you had the opportunity of following the laryngeal affection step by step, so to speak, through all its phases. The patient was a young man of twenty. He was placed in bed No. 4 of St. Agnes's Ward, laboring under one of the severest forms of dothinenteria, in which ataxo-adynamic symptoms predominated, and left behind them long-continued disturbance of the cerebral functions: during convalescence he was in a sort of imbecile state. During the third week of this young man's illness I observed symptoms involving the respiratory organs: there was dyspnoea, but the most charac- teristic indications were hoarseness and cough. On examining the back part of the throat I was enabled to ascertain that there was undoubtedly swelling of the epiglottis, and was led to suspect that it extended to the aryteno-epiglottidean folds-perhaps even<o the mucous membrane of the larynx and the vocal cords. By means of regular insufflation several times a day of alum and tannin there was a great amelioration, but not a complete cessation of the symptoms: under these circumstances he asked, and was granted, his dismissal. Believing, however, that there was deepseated mis- chief, localized probably in the cartilages of the larynx, I told you that there was necrosis of one of the cartilages, and stated my fears as to the 292 DOTHINENTERIA. fate of this young man: my impression was that in a few days he would return to the hospital in a worse condition, and requiring serious surgical intervention. In point of fact, ten days afterwards, he did return. My prediction was fulfilled: the symptoms had assumed a formidable severity. Respiration was oppressed: expiration, which was whistling, was less laborious than inspiration: the cough was exceedingly hoarse, there was an almost total absence of voice, and it was only by very great exertions that this unfortu- nate young man could make himself understood. Nevertheless, the oppres- sion not having proceeded to the last degree, and there being no threatening suffocation, I made a new attempt to subdue the symptoms, using the same means which had at first been successfully employed. I prescribed insuffla- tions of alum and tannin, but no abatement of the symptoms resulted from that treatment. With a view to give him a last chance before resorting to tracheotomy, I looked on the case as possibly one of syphilitic laryngitis, although only too well convinced of the accuracy of my diagnosis, and although I had hardly any hope of obtaining more favorable results. Profit- ing, therefore, by the time granted me, by the want of urgency in the symp- toms, I administered preparations of iodine; but under this treatment the oedema of the glottis increased, and, on the 18th July, there was a renewal of the threatening of suffocation; and, from asphyxia being imminent, it became imperative to resort to tracheotomy. The operation was performed late in the evening by the mferne on duty, M. Warmont, a distinguished hospital pupil, and next morning, at the visit, I found our patient in good spirits, and asking food. Some weeks afterwards he finally left the hospital, breathing freely by the wound in the trachea, thanks to a tube of very large calibre which had been inserted. When he wished to speak he closed the tracheal opening, and though his voice was still very hoarse, it was easily heard. He afterwards came to see us occasionally, and from time to time we have had accounts of him. Two years after the operation he was still breathing through the tube, which he could not close completely without being threatened with suffocation. His general health was excellent: at his last visit we found that he had gained a considerable amount of flesh. He had resumed work as a coppersmith. To render his infirmity more supportable, and for the purpose of concealing it as much as possible, he had invented a somewhat ingenious apparatus: he had adapted to his tracheal canula a long caout- chouc tube, which, passing under his neckerchief and descending along his body, opened in the side pocket of his trousers. When he wished to speak he put his hand into his fob, without, as formerly, having to put his finger to his neck. He was, however, obliged to renounce this contrivance, as it interfered with the freedom of his breathing. Some days ago I learned that he continued in the same state of health, but was still wearing the tracheal canula. Cases of oedema of the glottis, similar to those now related, occur not unfrequently in the course of, and during convalescence from, severe con- tinued fevers. I say severe fevers, because they are observed not in dothin- enteria only, but likewise in scarlatina and small-pox. At present, to speak only of what occurs in putrid fever, I may mention that my lamented col- league Sestier, in 274 cases which he collected, gives 10 cases in which oedema of the glottis supervened during convalescence from typhoid fever. These cases were not encouraging, for they all proved fatal; in five of them, tracheotomy was resorted to.* * Sestier: La Bronchotomie dans le cas d'Angine (Edemateuse. [Archives Generales de Medecine, 1850 ] DOTHINENTERIA. 293 In contrast with these unfortunate cases, I can quote others of a more favorable character, in addition to the two which I have already related. In the Gazette Hebdomadair e, for August, 1859, you will find a report in relation to this subject, by Dr. Charcot, of cases published in Germany, in which the proportion of successful cases was great,-seven in nineteen. What ought most to surprise you, gentlemen, is that cases of oedema of the glottis consecutive to dothinenteria are not more numerous, seeing the frequency of the lesions under the influence of which this affection may be produced. I have related to you the only two cases of this affection which I have met with as sequels of dothinenteria since I have occupied this clinical chair; so that I have had no opportunity of verifying by dissection the appearances which others have seen in similar cases. But that I may make my remarks on this subject as complete as possible, I will quote three cases, the first from my former pupil, Dr. Louis Genouville, the other two from Dr. Second-Ferreol.* Dr. Genouville's case was that of a person admitted to the Hospital of St. Anthony, to the wards of my colleague, Dr. Bergeron. The patient was at the end of a severe attack of adynamic putrid fever, when, a few days after his arrival, he was seized with a suffocative paroxysm which imperatively demanded tracheotomy. On the second day after the oper- ation, when he seemed sufficiently well to be allowed, at his own request, to discontinue the tracheal tube, he was suddenly carried off by a suffocative attack. On opening the body, the mucous membrane of the larynx was found to be gangrenous, and this condition extended back to behind the ventricles; the arytenoid cartilage was entirely destroyed ; the inferior constrictor muscles of the pharynx and the crico-arytenoid muscles were sphacelated. The bronchial glands were black, and exhaled the character- istic odor of gangrene. In the situation of the ileo-ctecal valve were seen the morbid appearances which belong to dothinenteria. In this history, there is nothing said of oedema of the glottis; but I nevertheless deem the case deserving of mention, for gangrene of the larynx and necrosis of the cartilages are lesions associated with oedema of the glottis, although gangrene is not so commonly met with as other morbid alterations, of which there are notices in the cases reported by Dr. Second- Ferreol, which I am now going to relate. One of his patients, a man of twenty-two years of age, had had a seriously complicated attack of ataxo-adynamic putrid fever: he had gangrenous sloughs over the sacrum, and the surfaces to which blisters had been ap- plied on the calves of the legs were sphacelated. On the 22d December he went into La Pitie Hospital, under the care of my excellent friend and colleague, Dr. Noel Gueneau de Mussy, and at the end of January was convalescent; his wounds, however, were not cicatrizing, and numerous subcutaneous purulent collections formed, which had to be opened. He had been subject to loss of voice before his typhoid fever, and had a return of this affection during the convalescence. He was not only voiceless, but had likewise difficult respiration, and the inspiration was whistling, par- ticularly during sleep. By cauterizing the superior orifice of the larynx with nitrate of silver these symptoms were temporarily moderated, but again increased when speaking was attempted. They soon became of such a character that suffocation was imminent, and tracheotomy necessary. The patient died during the operation. The autopsy showed a slight cedematous infiltration of the aryteno- * Bulletins de la Anatomique, for 1857 and 1858. 294 DOTHINENTERIA. epiglottidean folds; both vocal cords were swollen, and presented slight superficial erosions. The larynx contained a large quantity of muco-pur- ulent fluid, which, when pressure was made on the cricoid cartilage, flowed out through a fistulous opening, situated posteriorly and a little to the left side of the cricpid cartilage. This opening communicated with a collection of pus, bounded on one side by the sterno-thyroid, and crico-thyroid muscles, and on the other by the mucous membrane of the larynx. A great part of the left half of the cricoid cartilage had disappeared. There was a loss of substance, very irregular in shape, constituted by the destruction of the superior circumference of the ring, and involving three-fourths of its height. On each vocal cord there was observed a small club-shaped polypus with a slight pedicle, and about the size of a lentil. These two small polypi, at- tached opposite to each other, were floating loose ; and by falling down over the orifice of the glottis they could very well close it completely. These polypi may not have much complicated the necrosis of the larynx, but they accounted for the aphonia to which the patient was liable prior to his attack of typhoid fever. The subject of the second case was a young man of seventeen years of age, who likewise was received into Dr. N. Gueneau de Mussy's wards with typhoid fever. The attack, apparently slight at first, was marked, during the second week, by adynamic symptoms of, however, no great severity. On the morning of the eleventh day after his being received into hospital, he showed signs of excitement; the voice was hoarse, and sounded as if it were stifled : inspiration was noisy and whistling, while expiration was more easy. Frictions with croton oil on the neck, cauterizations of the superior orifice of the larynx with a solution of nitrate of silver in three times its weight of water, applied by means of a sponge, did not stop the symptoms, which indeed, by the evening, had become considerably aggra- vated. Redness was then visible on the isthmus faucium, and when the finger was directed to the orifice of the larynx, the epiglottis was distinctly felt to be swollen, so as in shape to resemble a round cushion with a cen- tral hole, and to extend towards the aryteno-epiglottidean folds. The patient died during the night. At the autopsy, the isthmus faucium had a permanent bright red color, and the glands in that situation were swollen, as were likewise the papillae circumvallatae of the tongue. There was a large oedematous infiltration, with vascularity of the submucous cellular tissue, situated at the orifice of the larynx, around the epiglottis: in form somewhat spherical and resem- bling a cherry, it extended into the interior of the larynx, and over the vocal cords, which were eroded at their free margins. At the anterior horn of the left arytenoid cartilage, at the insertion of the vocal cord of the same side, there was a small, oval, grayish erosion, with fringed irregular edges, which led to a deposit of concrete pus in the submucous cellular tissue of the gouttier e des boissons from two to three centimetres long by one and a half broad. The arytenoid cartilage presented to the eye no appre- ciable alteration, but its anterior apophysis was found denuded at the bottom of the erosion already described. The necroses of the larynx, which in the cases now detailed gave rise to the affection improperly termed oedema of the glottis, have (following a mechanism which I will afterwards explain) as their starting-point ulcera- tions which are almost always met with in this region in dothinenteria, as has been pointed out by Chomel. The term oedema of the glottis, I call improper, because the affection really occupies the glottis itself less than the aryteno-epiglottidean ligaments, that is to say, than the superior orifice of the larynx. I will afterwards return to this point, when I come to con- DOTHINENTERIA. 295 sider in a special manner the history of cedema of the glottis. These laryn- geal affections, described with the greatest possible care by Louis, exist so constantly, that that physician gives ulceration and partial destruction of the epiglottis as one of the secondary anatomical characters of dothinen- teric fevers, placing them in that category along with ulcerations of the pharynx and oesophagus. So characteristic are these appearances in his opinion that he says : " If found on examining the body of one who has died from an acute disease, they will establish with nearly perfect certainty, and without going any farther, that the affection was typhoid fever."* The cartilages of the nose may be affected by dothinenteric necrosis. We are indebted to one of our accomplished hospital colleagues Dr. Henri Roger for the account of a very curious case of necrosis of the cartilage of the septum. It occurred in a young man, who, when convalescent from very severe typhoid fever, attracted the attention of his physicians by an unusual phenomenon ; he had a perforation of the nasal septum, through which he could make his two fingers meet. There was shown to exist, in fact, an ulceration with perfectly rounded edges, bleeding at some points, and at others covered with crusts which circumscribed a complete destruc- tion of part of the septum, which was found to present a perforation of the size of a five centime piece. The cicatrization of the ulcerated soft parts was soon completed, but the perforation of the septum remained. It was of an oval form, and situated three millimetres above the orifice of the nostrils. The only functional disturbance which it occasioned was a snuf- fling sound of the voice, which at first was considerable, and then gradually diminished. Dr. Henri Roger very properly classes this case with those of necrosis of the larynx. It is, however, much more rare, for neither Roki- tansky nor Griesinger mention it. There is no example of it quoted by Cruveilhier; and I have never seen one.f These lesions admit of explanation, without the necessity of supposing a special localization of the disease analogous to that'which takes place in the intestinal canal. There always exists in dothinenteria, in a degree more or less marked, that irritation, that catarrhal condition of the respi- ratory passages to which I have called your attention : and on the other hand, it is known how much in this fever the tendency to ulceration shows itself, wherever there is inflammation or even mere irritation of the mucous membranes. You have not forgotten, I presume, what I told you, to the effect, that in septic diseases the mucous membranes become the seat of half active, half passive congestions, which readily proceed to inflammation and even to sphacelus, a fact which explains the ophthalmic affections of which I have spoken-the coryzas, sore throats, inflammations of the geni- tals, and laryngitic attacks, which, in fact, all belong to the common cor- tege of septic fevers. With this fact in your minds, you will not be aston- ished to meet with a tendency to ulceration, a tendency which is sometimes found where it would hardly be looked for. For example, Dr. Charcot had a case in which there was ulceration of the gall-bladder. It may, therefore, be said that there is a sort of ulcerous diathesis in dothinenteria ; but independent of this diathesis, of this dyscrasia of the blood, which constitutes one of the characters of putridity, ulceration is one of the consequences of inanition, as has been demonstrated by the beautiful experiments of * Louis : Recherches sur la Fievre Typhoide, p. 321. Paris, 1841. j- H. Roger : Bulletin de la Societe des Hopitaux de Paris. T. iv. p. 427. | Chossat : Recherches Experimentales sur 1'Inanition. Paris, 1843. 296 D0TII1NENTERI A. Likewise, there are no circumstances under which ulcerations of the larynx, nose, pharynx, oesophagus, &c., are more common than when the dothinenteria has been of the putrid form, adynamic, or when the course of the disease has been protracted, or when the diet of the patient has been kept too rigorously low. I intend, as I have already said, to reserve my remarks on the mechanism of oedema of the glottis, as I propose to devote an entire lecture to the consideration of that affection. There still remains a question for our consideration. When once oedema of the glottis has been ascertained to exist, ought tracheotomy to be imme- diately performed ? Ought we to wait for violent suffocative paroxysms ? Ought we to wait till asphyxia is imminent? You have seen, gentlemen, what I did in the case which came under your own observation. At the first examination, I diagnosed oedema of the glottis: paroxysms of suffocation occurred, but I still postponed opening the trachea, and instituted treatment, which, although I was not sanguine as to its success, nevertheless gave a chance of obviating the necessity of operating. I held myself in readiness for every eventuality : I caused the patient to be closely watched, resolving to perform tracheotomy whenever, from the suffocative fits becoming frequent and violent, asphyxia should become imminent. The young man was not operated on till it would have been dangerous to have waited longer. Such in my opinion is the proper course to follow ; for after balancing the indications for and against open- ing the trachea in oedema of the glottis, I would say that it is wrong to wait till asphyxia has proceeded so far as to render death imminent. To wait the arrival of that critical moment would be to run the risk of failure from the patient sinking during or immediately after the operation, in con- sequence of his having fallen into a state of stupor and collapse, from which it might be difficult to rouse him. On the other hand, it would be equally wrong to be in a hurry to operate as soon as severe and well-marked attacks of suffocation had occurred, and it would be equally objectionable to oper- ate as soon as oedema of the glottis had declared itself; for under both of these conditions, there are cases in which recovery takes place without tracheotomy. These recoveries seldom occur when the oedema depends upon necrosis of the cartilages of the larynx, because the necrosed portions, with hardly an exception, absolutely require to be eliminated, and this elimination cannot take place till repeated inflammations have been excited; and under their influence infiltration of the aryteno-epiglottidean folds is produced. Sometimes, also, the vocal cords are infiltrated, as I will after- wards explain to you. Nevertheless, gentlemen, it is quite possible for this elimination to take place without involving these consequences. When this occurs, recovery is the result of the unaided efforts of nature, as is exemplified by the fol- lowing case, which occurred iti the practice of my colleague Dr. Herard, physician to the Lariboisiere Hospital. A young woman of twenty-two had a very tedious convalescence from typhoid fever. After the lapse of about three months, she was suddenly seized with severe dyspnoea accompanied by loss of voice. From that time she had had occasional attacks of suffocation, during which the inspiration in particular was exceedingly painful. Six months later, the aphonia was almost absolute. The few sounds emitted by the patient were hoarse, gut- tural, and accompanied by a little hissing noise. Respiration was very much oppressed: inspiration, which was noisy and somewhat wheezing, brought the muscles of the chest into strong action. The patient had at the same time a frequent and very distressing cough, but it did not come in fits: the sound of the cough was very deep. There was a little sero- DOTHINENTERIA. 297 mucous expectoration slightly streaked with blood. The patient's general condition was good; her countenance had a natural appearance; she was plump; and had regained her strength. Examination of the respiratory apparatus only furnished negative signs. On applying the stethoscope over the larynx, a very decided whistling sound was heard: it was very rough during both inspiration and expiration, but particularly during inspiration. Externally, there was no sign of struc- tural change in the larynx-no cicatrix, no fistula, no crepitation on pres- sure-nothing to indicate lesion of the cartilages. On introducing the finger into the throat, it was impossible to detect any increased volume of the aryteno-epiglottidean folds; and a sound was easily introduced into the larynx. Some days later, the patient experienced more discomfort in the larynx: she thought that she felt a movable body which occasionally got across the throat. All at once, during the evening, she was seized with a real and very severe paroxysm of suffocation ; and after a violent fit of coughing, she ejected by the mouth two small osseous sequestra. On the immediately following days, the aphonia remained as before. The cough was distressing, and had all the characters of laryngeal cough. The larynx, when pressed, was slightly painful, but unless pressure was made, there was no sensation of pain in it worth noticing. At the end of a month, slight improvement showed itself. There was less cough; and the vocal sounds, though still very incomplete, were uttered with more ease. At the end of a residence of seven months, the patient left the hospital. Her general health was then unexceptionable: utterance was nearly natural, though the voice was still rather hoarse, guttural, and deep. There was no cough, and no pain in the larynx, even on pressure. The state of the chest continued satisfactory. In conclusion, when oedema of the glottis supervenes during convalescence from, or in the course of, dothinenteria, after trial has been made of the available therapeutic resources of medicine, such as insufflation of alum or tannin, cauterizations with nitrate of silver, and, when practicable, scarifi- cation of the oedematous aryteno-epiglottidean folds, we must be ready to perform tracheotomy-and that early rather than late-that is to say, when the suffocative paroxysms have become frequent and of increased severity and duration, and the respiration more embarrassed in the intervals between the fits. The more the patient has been reduced by the antecedent malady, the less delay ought there to be in operating. 3. Sloughs.-Erysipelas.- Colliquative Suppurations.-Paraplegia Consecu- tive to Infiltration of Pus into the Spinal Canal producing Inflammation and Suppuration of the Spinal Marrow. Gentlemen, the tendency to sphacelus, which is one of the characters of the condition to which the name putridity has been given in severe fevers, is never more decided than in adynamic dothinenteria. It,is the principal cause of the sloughs which you have so often observed in our patients. They occur chiefly in parts subjected to continuous pressure, such as over the sacrum, great trochanters, and, as Chomel has noted, sometimes even, over the occiput. Continuous pressure, then, contributes its share in causing mortification of tissues: the contact of faeces, and urine, by constantly soil- ing the parts, undoubtedly also assists in producing that result. It is neces- sary, therefore, that the patients should be kept exceedingly clean, and that their position should be frequently changed, so as to prevent the injurious consequences of pressure continued too long on the same part of the body. 298 DOTHINENTERIA. With a view to obviate the inconveniences which arise from the roughness occasioned by folds in the sheets on which the patient lies, napkins of vul- canized india-rubber have been invented for placing under the seat: they are stretched across, and fixed at each side of the bed. By this contri- vance, a perfectly smooth and soft surface is obtained: and these napkins have, moreover, the advantage of being easily kept clean, as that can be accomplished by wiping them with a wet sponge. When one has not at command an apparatus of this description, the pelvis of the patient may be wrapped up in a chamois skin, such as is used for washing carriages: it is fixed in front, so that whatever position the patients get into, they are always in contact with a smooth, soft surface. These chamois skins can be obtained anywhere; and they are very easily washed. Another plan sug- gested-a plan you saw me put in practice with one of our male patients- consists in making the patients sleep on straw, in accordance with the sys- tem adopted with the gateux* of the Bicetre and Salpetri&re. The straw absorbs the fluid part of the excrementitious matters, which by their contact would have irritated the skin; and in this way one of the causes of gangrene is removed. Unfortunately, these different measures often prove insufficient; for, as I told you, the principal cause of sloughing in dothinenteric patients is the tendency to mortification which belongs to the disease. How great this tendency is is seen by the facility with which surfaces to which blisters have been applied become gangrenous, even when the blisters have been applied to the front of the chest and insides of the thighs, surfaces on which there can be neither pressure, nor soiling by urine or faeces. It also often happens that pustules of ecthyma in different parts of the body and the bites of leeches become the starting-point of sloughs of greater or less size, and of more or less depth, irrespective of pressure or irritation from excre- mentitious matter, causes to which some physicians-as I think erroneously -attach very great importance. The sloughs which occur so frequently in dothinenteria sometimes become exceedingly serious complications. They may occasion erysipelas, which, developing itself around a slough, may spread widely, invading a great part of the skin, or exciting febrile action, which exhausts the patient, already much reduced by the long dura- tion of the putrid fever. From their number, extent, and depth, the sloughs are in themselves serious complications; for when they do not lead to a fatal termination, they exceedingly retard convalescence. Gangrene often proceeds from the skin to the cellular tissue, then reaches the muscles, and destroys them. Its destructive power affects even the bones, which it leaves denuded and ne- crosed. Under these circumstances, there are large deep ulcerations yield- ing a putrid sanguinolent discharge ; and ere long, life is terminated by the vain attempt of the organism to struggle against profuse and constant sup- puration. Moreover, the extensive ulcerations of the skin produced by the sloughs -as well as boils, carbuncles, and buboes-may lead to the absorption of putrid or purulent matter. Professor Andral mentions a case in which nu- merous metastatic abscesses supervened after an attack of small-pox.f * See p. 245. The gateux of the Bicetre, and the gateuses of the Salpetriere are the patients in the respective hospitals, who, from mental imbecility, or paralysis of the sphincters, pass their excrements either without regard to decency, or involun- tarily -Translator. f Andral : Clinique, t. i., p. 278: 3me edit. DOTHINENTERIA. 299 It is natural to suppose that in some cases the dothinenteric ulcerations of the intestines may become the starting-point of purulent fever. On the 16th December, 1861, a case of this description was observed at the anatomical theatre of the Hotel-Dieu. The autopsy to which I refer was that of a man of twenty-seven, who died, in the wards of my colleague, Dr. Horteloup, during the seventh week of typhoid fever. The symptoms which the man had latterly presented were such as are frequently observed in the last week of dothinenteria, just when convalescence ought to be begin- ning, and which consist in an exacerbation of symptoms, and the appear- ance of new typhoid and ataxic complications. When the intestines were being removed from the body, that they might be opened, it was observed that the most fleshy part of the left psoas muscle was swollen out into a tumor. When this was cut into, chocolate-colored pus spurted out, the quantity evacuated being estimated at nearly 100 grammes. Dr. Horteloup's interne, who made the autopsy, informed us that the patient had never presented the signs usually attributed to psoitis. I at once remarked that the psoas abscess must be metastatic, and that from appearances there were numerous similar abscesses in the lungs. The lungs were in fact studded with small purulent collections, such as are com- monly seen in the fever dependent upon the absorption of pus: similar puru- lent collections were found in the liver. We discovered nothing to explain the fact of purulent absorption, except extensive dothinenteric ulcerations in the lower part of the ileum. A similar case, in which recovery took place, is reported by MM. Castel- nau and Ducrest.* There is still another complication of dothinenteria which, although I have not seen it, may be met with. I allude to an inflammation of the spinal marrow and its membranes, which has a slough over the sacrum as its starting-point. You have seen a case of this description, though not in connection with putrid fever. The case, however, naturally claims notice in relation to the point now before us. Similar cases are also described in classical works. My colleague, Professor Nelaton, remarks, in his "Elements de Patholo- gie Chirurgicale," that, as a consequence of the sloughs which form over the sacrum, "there sometimes occurs an exceedingly serious complication, easily explained by the anatomical relations of the parts. The lower outlet of the sacral canal is closed by a fibrous band extending from the sacrum to the coccyx, and this band is itself involved in the mortification. The spinal dura mater and arachnoid are also perforated, and a putrid sanies flows into the arachnoid cavity, producing all the symptoms of spinal men- ingitis, and ere long causing death." This statement is quite a description of the case of the patient whom you lately saw in bed No. 8 of St. Agnes's Ward. Having presented the signs of acute myelitis, with sloughs over the sacrum, and typhoid symptoms, she sank delirious after an illness of six weeks. On examination after death, the entire posterior aspect of the space between the trochanters was found to be occupied by a slough. The sacro-coccygeal ligament was destroyed: the vertebrae were to a considerable extent denuded, and a probe could be introduced into the sacral canal. The membranes within the sacral canal were reduced to a greenish pulp, and it was impossible to recognize the arachnoid. There was a great quantity of pus as high up as the seventh dorsal vertebra: it seemed to have originated in the slough of the integu- * Castelnau et Ducrest : Recherches sur les Abces Multiples compares sous leurs differents rapports. Paris, 1846. 300 DOTHINENTERIA. merits. Up to the seventh dorsal vertebra the membranes of the spinal cord were thickened, but above that they were in a normal condition. Down to four centimetres above its termination in the cauda equina, the spinal cord, throughout its whole extent, was unaltered by any morbid affection. There it was in a softened condition, and under a jet of water it became disintegrated. There was no lesion of the encephalon. This was evidently not a case of dothinenteria: but you can very well understand that consequences similar to those now described might follow from sloughs arising in connection with dothinenteria, and it is on that account that I have related this history. 4. Spontaneous Gangrene of the Limbs. Among the local complications which may supervene during the course, and in the decline, of dothinenteria, one remains to be mentioned, which is very much rarer than any of those to which I have as yet directed your attention. I refer to spontaneous gangrene of the limbs, an affection to which in recent times particular attention has been paid. I have not seen any cases of this complication ; but you will find some reported by most trustworthy physicians. Among others I would mention those which Dr. Gigon of Angouleme has made the subject of a paper entitled, " Note sur le Sphacele et la Gangrene Spontanes dans la Fievre Typhoide and two cases read, on the 14th January, 1857, before the Hospitals Medical Society, by Dr. Bourgeois of Etampes.f To them I will add the following case, com- municated to me by my chef de clinique, Dr. Leon Blondeau, who saw it when interne at the Children's Hospital. A boy, of ten years of age, was admitted, on the 3d December, 1847, to the wards of Baudelocque. He fell ill at the beginning of November; and, from the accounts of his illness given by his family, there could be no doubt that he had had adynamic putrid fever. On admission, that of which the little patient most complained, was great pain in the right leg, in which, however, neither change of color nor swelling could be seen. Baudelocque had the idea that the pain was caused by the formation of one of those deepseated phlegmons which are sometimes met with in severe fevers : he, therefore, prescribed mercurial inunction over the seat of pain. Ten days afterwards, however, gangrene began to show itself in the foot. The boy was then taken into the surgical wards of M. Paul Guersant. The entire surface of the right foot was of a purple color, which was deeper on the internal aspect, from the tip of the great toe to the first line of tarsal bones. This violet hue, which might be compared to that of a naevus, extended to the third interosseous space of the metatarsus. Upon the ankle and internal malleolus, the veins were marked by greenish-brown subcutaneous lines, like those seen in putrefying dead bodies. The feeble heat still retained by the parts in this mortified condition was more attribu- table to precautions taken to keep the foot wrapped up in flannel and wad- ding, than to the temperature of the foot itself. There was complete absence of pulsation in the right tibial artery. On the internal and posterior surface of the right leg, at the junction of its upper and middle thirds, and in the course of the artery, a large hard cord was felt: it was felt most distinctly at the tibial insertion of the gas- * Gigon: See Union M6dicale for 24 and 28 September, 1861. f Bourgeois: See Archives Generales de Medecine for August, 1857. DOTHINENTERIA. 301 trocnemius internus. The slightest pressure over that place occasioned acute pain. On that side of the limb, the pulsations of the popliteal artery could not be detected, but the pulsations of the crural artery had the same force, frequency, and rhythm as in the left thigh. The inguinal glands were swollen : those of the right side were the largest, and the most painful on pressure; and over them the skin was of a pale red color. The pulse at the wrist was small, very compressible, and 100 in the minute. The patient was in a state of great excitement, and seemed to be suffering much pain. Six leeches were applied to the seat of pain in the leg, with apparently the result of giving some relief, by diminishing the acuteness of the con- stant pain : but the sphacelus went on increasing, the livid color of the skin became of a deeper shade, and spread itself over a larger surface. Tonic regimen and tonic medicines (including cinchona as the chief) were prescribed. The limb was at the same time kept enveloped in opiated poultices. On the 16th December, three days after the boy's admission into M. Guersant's ward, there was a complete demarcation between the gangren- ous and non-gangrenous parts. Next day, the vascular cord could not be felt; and the fever had subsided. On the 29th December, the gangrene seemed to be perfectly circumscribed in the region which I have just described : it appeared to be very superficial, and not to go deeper than the skin. Over the malleoli, and in particular over the malleolus externus, some brownish lines were visible, formed by veins gorged with stagnant blood. The boy complained of very acute pains in the affected parts, which were, in general, most severe at night. The pains in the legs had completely ceased. The general condition of the patient was very satis- factory. Notwithstanding the severity of the lesions, the boy-after having had his foot amputated-perfectly recovered, and left the hospital on the 17th May, 1848. In this case, gentlemen, the gangrene, which supervened in the wane of an attack of dothinenteria, undoubtedly originated in obliteration of an artery. The question, however, still remains, whether the arterial oblitera- tion was the consequence or the cause of arteritis, the existence of which arteritis was characterized by the presence, in the course of the artery, of an indurated cord, painful to pressure. My own opinion is that in this case, as well as in the two cases of Dr. Bourgeois of Etampes which I am about to relate, as likewise in cases published by Dr. Gigon of Angouleme, and Dr. Patry of St. Maure, the primary cause of the gangrene was the formation of a clot-plug, this clot having been either formed in situ, consti- tuting the thrombus of Virchow, or being a migratory clot, the embolus of the German professor. This clot, acting as a foreign body on the inner surface of the vessel, had excited inflammation in it, which inflammation in its turn had produced plastic products, and in this way the stoppage in the artery had been increased, and its obliteration had at last been completed. The subject of the obliteration of vessels by self-made clots [caillots autoch- thones']-to use the current term of the day-is of so much importance that I must devote one or more of our meetings to its consideration. It is, moreover, so often met with in practice, that we shall certainly have an opportunity of returning to it; and I, therefore, reserve our special study of it and its bearings upon clinical instruction. Let us now return to the subject more immediately before us. The cases of Dr. J. Bourgeois of Etampes are even more interesting than the case I have just related to you, from the circumstance that in them the sphacelus 302 DOTHINENTERIA. was deeper and more extensive, in one case involving the whole of the leg, and in another case involving both legs, causing in both instances ampu- tation of limbs by the unaided efforts of nature. In the young girl, the subject of his first case, there came on, in the wane of a mild attack of dothinenteria, acute pain in the right leg, which was neither red nor swollen, but in which there was a notable diminution of motor power and sensibility, and a reduction in temperature : after a few days, the leg was quite cold. The skin soon assumed a color which at first was dark gray, then copper-red or brick-red, and quickly afterwards became clear violet with numerous streaks. The physiological sensibility of the leg was so completely extinct that a pin could be pushed in its whole length without causing any annoyance. An irregularly fringed line, separating the obviously mortified from the still living parts, extended from the tuberosity of the tibia to the upper third of the calf, and encircled the leg. The integuments losing their violet hue, became more and more slate-colored. At the point of contact of the healthy and diseased parts a deep ulceration formed, from which there was every day a flow of gray- ish, very fetid pus. The knee was slightly painful: in the thigh, there was no pain. The toes and the foot dried up, but the leg, well nourished, long retained its natural size. The patient's condition, however, improved from day to day. She was kept on restorative diet, and tonic medicines. The leg was covered with powders of an absorbent aromatic and septic char- acter. The soft parts very soon separated: the living flesh retracted, leaving between the healthy and modified parts a space of from four to five centimetres, in which were seen the two bones of the leg, perfectly denuded, dry, and almost white. To rid the patient of a fatiguing weight, and a source of exhalations more or less injurious, the bones were sawn through at two centimetres from the wound, which had a sound red appearance, and was even beginning to cicatrize at its edges, and to contract. Twenty days afterwards, two small rings of bone were detached; and then cicatrization was soon completed. The girl left the hospital, having regained her fresh looks and plump appearance. The stump was exactly similar to stumps obtained after amputations performed at a selected spot, and in the best possible manner, according to the rules of art. Dr. Bourgeois states that he did not find any swelling in the course of the great vessels. It is probable, however, that in this, as in the other case I related, the gangrene was the consequence of obliteration of the popliteal artery. This remark is applicable also to Dr. Bourgeois's other case, which I am now going to narrate. No painful cord caused by the obliterated artery was observed, although it was noted that there was entire absence of pulsation in the arteries of the mortified limb. Here is an abstract of the case. The patient was a boy of twelve years of age. At about the third week of a moderate attack of mucous fever, and just when convalescence seemed to be beginning, he was seized in both legs with very acute pain, which was most severe in the right: the pain was increased on pressure, but was unaccompanied by any swelling. There was a decrease of temperature in the legs : the thighs presented nothing abnormal. After two or three days, the surface of the right limb assumed a grayish tint, which passed into a copper-red, traversed by numerous streaks. The pain was most intense below the tibio-femoral articulation. The integuments had lost their sen- sibility, and the paralysis was complete. A deeply-indented line had separated the living from the sphacelated parts. Scarcely a week later, similar changes were occurring in the left DOTHINENTERIA. 303 leg. The patient was admitted to the hospital at Etampes, where Dr. J. Bourgeois observed the progress of the malady from day to day. The boy died after nine months of dreadful suffering. The natural separation of the dead parts was, you observe, waited for. Although it was obvious that there were some objections to thus allowing the dead parts to remain, it was supposed that as they were perfectly dry, and far separated from the stump, the evil consequences could only be very slight. It is to be regretted that there was no autopsy. Had an examination of the body been made after death, there would probably have been found not only an obliteration of the vessels of the thigh, the pulsations of which were felt during life, but of the popliteal arteries ; and thus a complete explanation would have been afforded of the spontaneous gangrene of the limbs, without the necessity of having recourse to the very questionable hypothesis of disturbance of the functions of the nervous system, or with- out requiring to invoke, with Dr. Bourgeois, a metastasis, of which really I can form no conception. Two of the cases observed by Dr. Gigon of Angouleme presented a remarkable similarity to those which I have already laid before you, with these differences, however, that it was not an inferior extremity which was sphacelated, but the right superior extremity, and that the gangrene was moist and not dry. This latter difference is explained by the affected part being different, and-as the autopsy showed-by the vascular obliteration being in the veins and not in the arteries. " In two patients," says Dr. Gigon, " suffering from very severe typhoid fever with symptoms of putridity of the humors, there arose in the right arm considerable swelling, which was greatest in the neighborhood of the axilla. The hand and forearm were least swollen. The arm was at first red, and painful to the touch, and then it swelled to twice its natural size: its skin became purple, its temperature fell, its sensibility became obtuse, numerous phlyctsense (filled with a yellow or reddish fluid) showed them- selves, and some brown patches appeared below the shoulder and towards the elbow. Incisions, large and deep, made both before and behind, throughout a great part of the length of the arm, were hardly felt by the patient: the subcutaneous cellular tissue was deeply gangrenous, and infil- trated with pus. Shreds of gangrenous cellular tissue became detached, along with portions of aponeurosis, and there was a discharge of sanious, reddish, putrid purulent matter. The symptoms of general prostration in- creased greatly at the same time; and led to speedy death. In one case, eight days, and in the other nine days, elapsed between the appearance of the swelling and the fatal issue. The gangrenous affection seemed to be much more serious in the superior than in the inferior extremity. The autopsy showed that in both cases there had been inflammation of the su- perior portion of the subclavian vein, with formation of a complete clot- plug, which adhered to the inside of the vein : the clot was of pretty firm consistence, of a rose color, and acted as a stopper. Less tenacious rami- fications of the clot extended into neighboring veins, such as the superior scapular, the axillary, the cephalic, and external mammary: in the sub- clavian vein, the internal surface was of a very deep red, this color, as the vessel advanced, diminishing towards the ramifications: the venous coats were more friable than natural, and thickened. The mechanical obstacle to the circulation was, in my opinion, the cause of the moist gangrene of the arm." Dr. Patry of St. Maure* reports the case, of a patient who had simul- * Patry: Gangrene des Membres dans la Fi&vre Typhoide. [Archives Generales de Medecine, et mai, 1861.] 304 DOTHINENTERIA. taneously dry and moist gangrene in different parts of the same inferior extremity. The dry gangrene occupied the foot and leg, which were black, dried up, and shrunken: the moist gangrene was spread over the whole thigh, which was purple, swollen, and denuded of epithelium in several places. On examination after death, the crural artery was found to be in- creased in size, and completely obliterated at its upper part by black clots, which broke down easily, and were not adherent to the interior of the ar- tery : in the popliteal portion of the vessel, the clots were friable and harder, and some of them were adherent to its inner surface: the arterial coats were red, injected, thickened, and had lost their elasticity. The crural vein was obliterated by consistent Jdack clots, which, however, did not adhere to the internal tunic : its coats were thickened, injected, of a deep red color, and did not collapse when cut. The dry gangrene of the foot and leg is evidently explained by the obliteration of the popliteal artery, which took place before the obliteration of the crural artery, in which the clots were more recent, softer, and non-adherent. The moist gangrene of the thigh was equally the result of the obliteration of the crural artery and the crural vein: there was a combination of gangrene arising from suspension of the arterial circulation, and of oedema from arrest of the venous circu- lation. Dr. Patry has also given the very curious history of a young man who, at the twentieth day of an adynamic dothinenteria, suddenly felt a very acute pain, proceeding from the left angle of the inferior maxilla to the parotid and temporal regions. In forty-eight hours from the commence- ment of this pain, the left ear sphacelated. Subsequently, the parotid and temporal regions became cold, and assumed a purple color, while bullae, filled with a blackish fetid fluid, appeared on their surface. Four days latter, the sphacelus had extended to the forehead, to both eyelids, and to the cheek, as far as the commissure of the lips. In spite of these frightful disorders, the patient survived twelve days. At the autopsy, the external carotid artery was found to be obliterated by two clots, one of which, situa- ted in the upper part of the vessel, was hard, friable, colorless, and adhe- rent ; and the other, more recent, and striated lower down, was of a deep black color, and tolerably consistent. In the situation of the upper clot, the arterial canal was injected, thickened, and more easily torn than nat- ural : the inner coat had lost its smoothness and transparency. The jugular veins were in a normal state. In connection with this case, Dr. Patry mentions that he saw, in 1843, in the hospital practice of Dr. Charcellay of Tours, a man who was, dur- ing dothinenteria, attacked with gangrene of the whole of the left side of the face, and who was for five months a sufferer from this complication. Both the right and left superior alveolar arches were destroyed, and the patient was obliged to wear a bandage over the left side of the face, so as to conceal the hideous enlargement of the mouth. To complete this series of abridged cases, it is necessary to add, that the typhoid fever in which the complications arose was characterized by find- ing, during life and after death respectively, the symptoms and lesions peculiar to that disease-a fact which both Dr. Gigon and Dr. Patry are careful to state. If obliteration of an artery or vein is the undoubted cause of sphacelus of an entire limb, or of a great part of a limb, arising in the course or at the end of dothinenteria; if this obliteration of vessels, if the arteritis or phlebitis which have been active agents in producing it, have for a starting-point a sanguineous clot, the formation of which (as I remarked when speaking of embolism) ought to be attributed to a peculiar dyscrasia of the blood met with in other diseases very different in their nature from TYPHUS. 305 typhoid fever-it is also indisputable that the mechanical cause acts much more energetically in dothinenteria, from the circumstance that a notable tendency to mortification of tissues is one of the characteristics of the putridity at times so strongly marked in that fever. LECTURE XVI. TYPHUS. An Infectious Disease like Dothinenteria.-Differs from Dothinenteria in the Absence of Intestinal Lesions.- The two Fevers are distinguished from each other by the Aggregate of the Symptoms, and their Thermal Varia- tions. Gentlemen : Although, from the nature of the instruction which it is my duty to impart to you, there is a propriety in confining myself to the consideration of the clinical cases which come under your observation, and to their elucidation from the results of my personal experience, I still think that I may to-day speak to you about a disease which we have never had an opportunity of seeing in our wards, but which is certainly well known to you by name. I speak of typhus, which, at least in the totality of its general symptoms, presents so great a resemblance to dothinenteria that the question of the identity of the two diseases, after having been for a long time under discussion, is still far from being settled, although the partisans of non-identity seem now to be the majority. Epidemic in some countries-notably so in the Britannic Isles-where after having reigned exclusively, first in Ireland, and then in Scotland, it seems now to be permanently installed in some of the manufacturing towns of England, particularly in London, where, in recent years, it has com- mitted great ravages. From the accounts of the disease-described under very various names*-furnished by old and modern authors, it appears that epidemics of typhus, originating under the influence of the same causes, and propagated by contagion, have in all periods of history ap- peared at various epochs, in the Old World and in North America. France, though not exempt from epidemics of typhus, has suffered less from them than other countries. Without going back to remote periods, it will be sufficient to remind you that during the first fifteen years of the present century, typhus, following the armies which were then overrun- ning Europe, broke out on several occasions in a considerable number of places in France ; and that it has since reappeared, for example, at Toulon in 1820, 1829,1833, 1845, and 1851 :f at Rheims in 1839 at Strasbourg * Fibvre Pestilentielle, Febris Pestilens : [Fracastor, 1546.] Typhus des Camps, Typhus des Prisons: [Sauvages, 1759.] Fievre Petechiale, Febris Petechialis: [Sennertus, 1641 : Selle, 1770, Borsieri, 1785.] Typhus Exantheinaticus: [German authors.] Spotted Fever, Typhus Fever: [English authors.] + Keraudren : Typhus dans les Bagnes de Toulon. [Arch. Gen. de Medecine, T. iii, 1833.] Fleury : Histoire de la Maladie qui a regne parmi les condamnes du Bagne de Toulon, 1829. [Mem de I'Acad, de Medecine, T. iii, 1853.] Barraillier: Du Typhus Epidemique & Toulon. Paris, 1861. + Landouzy : Arch. Gen. de Medicine, 1842. vol. i.-20 306 TYPHUS. in 1854:* and that in 1856, imported from the Crimea, where our soldiers imbibed its germ during the war in the East, it declared itself in several other towns, among which were Marseilles, Avignon, and even Paris, where as you know, in the military hospital of Val-de-Grace, it prevailed as an epidemic from January to May of this year 1856.f I have said that typhus seems always to arise under the influence of the same causes. This is a point upon which all physicians are agreed. All admit that the morbific matter, the poison, the miasm which engenders the disease, can be spontaneously developed wherever great masses of human beings are accumulated, as in the great centres of population, in armies con- centrated within a space too small in relation to the number of persons, in prisons, and in ships. This is particularly the case in ships used as penal hulks, if the men are exposed to bodily fatigue, mental anxiety, moral suf- fering, and dieted with food bad in quality, and insufficient in quantity. But I also stated, that when typhus is once developed in a locality, it often spreads by contagion, when one cannot point to any other cause for this propagation taking place. Bear also in mind, that in respect of typhus, as in respect of all other contagious diseases, it is not necessary that the con- tagion be transmitted by persons who have the disease: it may be carried by individuals who have not, and who have never had, the malady, the morbific germ of which they are the means of transmitting. This fact-an incontestable acquisition of science-suggests the fear that from the constantly increasing intercourse between the two countries, typhus, at present in permanence in England both in the epidemic and sporadic form, will pass over into France, and establish itself among us for a longer or shorter period. It is, therefore, my duty, gentlemen, to give regarding this disease some information, which you may soon, perhaps, have to make use of in practice. This information I will take from a work published by Dr. Murchison, physician to the Fever Hospital of London.£ Dr. Murchison discusses the question of the identity or non-identity of typhoid fever and typhus, and declares himself a believer in their non-iden- tity. This is a subject to which I shall have to return. Dr. Murchison states in the preface to his book, that after having been brought up in the opposite belief, he was led by his own observations to adopt the views of Drs. Stewart and Jenner, and that therefore his present opinion cannot be attributed to preconceived ideas. The invasion of typhus is usually sudden, but it may be preceded by a slight indisposition of one or several days' duration, characterized by gen- eral lassitude, vertigo, a little headache, and loss of appetite. Without premonitory symptoms, the patient is seized with transient, irregular rigors, followed by moderate perspiration: he complains of frontal headache, prostration, and a bruised feeling rendering every kind of move- ment painful, of pains in the loins and limbs (particularly the thighs), and of loss of appetite. During the first two or three days, although the skin is hot, even burning hot, he constantly complains of cold, and places himself close to the fire. The tongue is large, pale, covered with a fur which is at first white, and soon becomes yellow or brown. The taste is vitiated : there is thirst, more or less urgent, which causes the patient to desire every kind * Forget : Preuves Cliniques de la non-identite du Typhus et de la Fievre Ty- phoide. [Comptes Rendus de I'Acad, des Sciences, 9 Octobre, 1854.] f Godelier: Memoire sur le Typhus observe au Val-de-Grace. {Bulletin de VAcad, de Medecine, 1856, T. xxi, p. 889.] X Charles Murchison: Treatise on the Continued Fevers of Great Britain. London, 1862. TYPHUS. 307 of drink, but he soon loathes them all except cold water. Sometimes, there is nausea, and much more rarely, vomiting of bilious matters. The abdo- men, generally supple, and sunk rather than distended, is neither the seat of the slightest pain, nor is even sensitive to pressure. The bowels are gen- erally constipated. The urine is thick and high-colored. Usually, the pulse is full, but compressible: in some cases, it is hard and bounding, while in others, it is irregular and intermittent. There is a notable variety in its frequency: it sometimes rises to 120, and may afterwards go up to 150, which is one of the most threatening symptoms which can occur ; or it may, on the contrary, remain below the normal standard, even falling so low as 28. This is frequently an indication of feeble action of the heart, which in such circumstances contracts twice for each arterial pulsation. Respiration is more or less accelerated: and there is frequently decided oppression of the breathing accompanied by cough and mucous expectora- tion, under which circumstances there are heard on auscultation sonorous rales, indicating the existence of bronchial catarrh. The face is red : the margins of the eyelids are swollen, the conjunctivae injected, and the eyes suffused with tears. At first, the expression of the countenance indicates languor and fatigue, but it soon becomes sad, heavy, and stupid. From the beginning of the attack, there is vertigo, singing in the ears, restlessness, and often complete insomnia, while it also happens that the patient says that he has not slept, although his attendants have seen that he had been asleep for hours. This sleep, however, is disturbed by distressing dreams, and by a wakings with a sudden start: after three or four nights, the patient speaks in his sleep or in a semi-delirious state between sleeping and waking. When he awakens, he is conscious of what is passing around him, although his memory and intelligence are a little confused. From an early period, and rapidly, the prostration of the muscular force goes on increasing. He walks with tottering gait: when asked to hold out the hand, it is seen to tremble: this tremulous movement is also observed in the tongue, when an attempt is made to protrude it beyond the mouth. The feeling of debility and exhaustion soon becomes so great that about the third day from the beginning of the disease, the patient is unable to leave his bed. Between the fourth and seventh day-generally about the fourth or fifth day-the eruption appears on the skin. It consists of numerous irregularly shaped spots, varying in diameter from a mere point to three or four lines. The spots are either isolated, or they are grouped like pieces of marquetry in irregular forms, often recalling the appearance of the eruption of measles. At first, they are of a dirty rose color, or they present a sort of bloom, and are slightly elevated above the skin : they disappear when pressed by the finger: from the first or second day, they become of a darker brown shade, no longer disappear, but only become pale when pressed by the finger. Their margins are ill-defined, and blend insensibly with the general hyper- tejnic hue of the skin. They usually appear first on the abdomen, then on the chest, back, shoulders, and thighs; in some cases, their first appearance is on the backs of the hands. They are most frequently met with on the trunk and arms, and are rarely seen on the neck or face. They are always most obvious on the dependent parts of the body; and in doubtful cases, it is on the posterior parts and the back that they ought to be looked for. Besides the superficial spots, there are others paler, and less distinct from one another, which, from their being apparently situated under the epider- mis, are called subepidermic. When these subepidermic spots are abun- dant, they give the skin a wavy marbled aspect, in contrast with the darker and better defined spots formerly described, although sometimes both spots seem to be blended together. There is great variety in the appearance of 308 TYPHUS. the eruption of typhus, according to the relative abundance of the wavy or distinct spots. In some cases there is a profusion of both kinds, and in other cases there are not many of either. There is also a diversity'in the appearance of the eruption, dependent upon the greater or less degree in which it is confluent. The marble-like spots constitute what Jenner has described under the name of the mulberry rash, and which other physicians have called measly or rubeolous. In two or three days the eruption is com- plete ; or, at least, if new spots appear at a later date, they do not attain a full development. The severity and duration of the malady are propor- tionate to the quantity of the eruption and the darkness of its hue. Such is typhus during its first six or seven days. Towards the end of the first week the headache ceases, and delirium supervenes. The delirium varies in its character; occasionally it is, at first, acute, the patient screaming, talking incoherently, and being more or less violent. He will, unless placed under restraint, get out of bed, walk up and down the room, or even jump out at the window. This state of violence is generally followed by a period of collapse, during which the patient is calm, and speaks mutteringly in a low voice. As a rule the delirium is not violent, even at its commencement. Whatever may be its form, it is ac- companied by insomnia, and its manifestations are excited by speaking to the patient. The expression of the countenance becomes more sombre, sadder, and more stupid, the prostration at the same time increasing from hour to hour. The symptoms of nervous excitement are generally most severe in the evening and during the night, while the prostration is greatest in the morning. At this period of the disease, the tongue is tremulous, dry, brown, and rough in the centre; sordes accumulate on the teeth and lips; the bowels remain confined. The pulse ranges between 100 and 120; it is sometimes full and soft, but more frequently is small and feeble. In respect of the respiratory movements, there is also a great variation; the inspirations vary from twenty to thirty in the minute, but they may retain their normal frequency, or they may fall as low as eight, when the pulse is small, and the action of the heart exceedingly disturbed. Again, respira- tion may be spasmodic or jerking: this is the case when the cerebral symp- toms are very severe, as when there is delirium followed by coma. Finally, respiration may also be irregular, the inspirations succeeding one another with extreme rapidity; and also, it may be purely diaphragmatic, the muscles of the chest being seemingly paralyzed. This nervous respiration does not depend on any affection of the respiratory apparatus, and is an extremely serious symptom. The breath of the patient is fetid. The skin, colder than during the first week, dry, or slightly glutinous, exhales a pe- culiar odor, which may be compared to the smell of rotten straw, of deer, or of mice, but which is really a smell sui generis. The color of the erup- tion becomes darker; and towards the middle of the second week, there appear true petechise of a purple or bluish tint, which may be developed in the centre of many spots, with the brownish-red of which the margins of the petechiae become gradually blended. After three or four days, consequently about the tenth or eleventh day from the beginning of the malady, cerebral oppression, or stupor, takes the place of nervous excitement. The stupor at first alternates with the delirium, which is greatest during the night. There is extreme prostration: the patient lies on the back, groaning and muttering incoherently, or he remains quiet and at rest, but showing a tendency to get down to the bottom of the bed. He is quite unable to raise himself up, or even to turn on his side: he is raised with very great difficulty, and is wholly indifferent to surrounding persons and things. At this stage there are often tremors, startings of the tendons, TYPHUS. 309 and picking of the bedclothes: the look is haggard, and there is an expres- sion of stupidity in the countenance : the conjunctivae are injected, the eye- lids are nearly closed, and the pupils are contracted. Deafness is common. When addressed in a loud voice the patient looks around him with an as- tonished gaze, and when told to put out his tongue, he opens his mouth, and keeps it half open till ordered to shut it. These are the only indica- tions of consciousness which he gives, and they, even, are sometimes wanting. His mind, however, is far from being inactive: he dreams the most frightful dreams, which he implicitly accepts as realities, and of which he retains a complete recollection after his recovery. His thoughts turn upon the events of his past life. He fancies that he is persecuted by the persons around him, even by his dearest relations: he compresses years into hours, and in a few hours imagines that he has lived a lifetime. Those only who have experienced this mental suffering can form an idea of its intensity. The teeth and lips are covered with sordes: the tongue is hard, dry, brownish- black, gathered up into a sort of ball, and is either protruded with difficulty or not at all. The abdomen is flaccid, or sometimes tympanitic. The bowels are confined, or, two or three times a day, stools of rather diarrhoeal char- acter are passed involuntarily. There is an increase in the quantity of urine, but it is paler than natural, and below the normal specific gravity: it is passed involuntarily, or there is retention, necessitating the use of the catheter. The skin becomes still colder, and is occasionally somewhat moist. There is an increase in the number of petechial spots. The parts of the body subject to pressure, particularly the sacral region, become red and soft, and are apt to ulcerate. The pulse is rapid, ranging between 120 and 140, small, often of an intermittent character, irregular, and scarcely perceptible: the cardiac impulse, and the sounds of the heart, have either become diminished in intensity, or have ceased to be audible. The patient may remain in this condition, with life in the balance, for some hours or several days, till at last stupor merges into profound and fatal coma: or, he dies from asphyxia, consecutive upon sudden engorge- ment of the lungs : or, the pulse becomes imperceptible, the skin being cold, livid, and bathed in profuse sweat, death generally taking place without a return to consciousness, but without stertor occurring, and being apparently the result of syncope rather than of coma. The issue is not, however, always fatal. Towards the fourteenth day of the disease, a more or less sudden amelioration may occur. The patient falls into a calm sleep, which lasts for several hours, and from which he awakes a new man. At first, he is bewildered, and does not know where he is : by and by, he recognizes his attendants and friends, and becomes aware of his extreme weakness. His extremities retain their sensibility, but when he attempts to move them, they seem as if they did not belong to his body. The pulse has become stronger and less rapid : the tongue is clean, and at the edges is moist: there is some desire for food. These symptoms of amend- ment are often accompanied by slight perspiration, diarrhoea, or sediment in the urine. After two or three days, the tongue becomes quite clean, the appetite insatiable, and the pulse normal, or even, it may be, very slow. There is a rapid return of strength. Convalescence, in fact, is complete. Gentlemen, this picture, drawn by Dr. Murchison, represents to you a case of uncomplicated typhus. The disease, however, presents great va- rieties in respect of severity, and the relative predominance of adynamic or ataxic symptoms. In cases of average severity, the tongue is never dry nor brown, the pulse is never above 100, and the eruption is never petechial. A slight confusion of memory and the intellectual faculties, with disturbed sleep, seem to be the only cerebral symptoms which show themselves. Local 310 TYPHUS. complications, however, may modify the progress and character of the attack. Of these complications, which vary with the epidemic and the locality, the most common are affections of the respiratory organs. Chest complica- tions generally supervene insidiously, the usual symptoms of cough and ex- pectoration being insignificant or wholly wanting, and the patient making no complaint of pain. Under such circumstances, the rapid breathing,and lividity of the countenance, are the only signs indicative of a pulmonary affection; but rapid breathing is not in itself a conclusive sign, because, as I have already said, it is a frequent accompaniment of fever, and may exist in a very aggravated form irrespective of any important lesion of the respi- ratory organs. Moreover, if dyspnoea dependent on an important lesion declares itself by lividity of the face and hands, that lividity does not ap- pear till the complication on which it depends is far advanced, and often not till it is irremediable. When, therefore, there is the least doubt as to the nature of the affection, the chest ought to be examined by auscultation and percussion. Bronchitis is perhaps the most common of all the complications of typhus. In some epidemics, it is met with in the majority of cases. In Ireland, bronchitis is so usual a complication, that the typhus of that country has been called catarrhal typhus; and German physicians, including Rokitansky, who have derived their knowledge of typhus from descriptions of it as seen in Ireland, believe that it is nothing more than a thoracic form of dothin- enteria. Bronchitis may be the first symptom of typhus, or it may come on during the course of the disease, and continue during its decline. It is necessary to watch carefully all cases in which there are bronchitic symp- toms. There is no immediate danger, when the only signs of pulmonary affection are an occasional cough and some scattered sibilant rales: but when the prostration increases, the thoracic inflammation is liable to extend suddenly, and at the same time insidiously, and to become more or less as- sociated with hypostatic engorgement. Under these circumstances, cough- ing and expectoration being impossible in consequence of paralysis of the bronchial muscles, the catarrhal secretion accumulates in the bronchial tubes, and induces asphyxia. I have thought it best to give you a nearly exact translation of Dr. Murchison's description of this complication, on account of the frequency of its occurrence; but it will suffice merely to enumerate the others. Hypostatic engorgement of the lungs is described as a complication of typhus. Coming on generally at a more or less advanced period, about the eleventh or fourteenth day, sometimes earlier-as early sometimes as the seventh day-and being usually associated with bronchial catarrh, it is the most common cause of death in English typhus. Hypostatic engorgement must not be confounded with that acute pneumonia, in which there is exu- dation of plastic lymph into the pulmonary cells and intervening cellular tissue-a form of pneumonia which is very rare. Hypostatic engorgement sometimes terminates in pulmonary gangrene, particularly in persons, who, prior to their attack, have been ill-fed. Pleurisy is another but a rare com- plication of typhus. When it does occur, it is latent. Phlegmasia alba dolens often supervenes in the decline of typhus, but less frequently than in the decline of typhoid fever. Purulent infection with articular abscesses is rarer still. When it does occur, it proves rapidly mortal. Scorbutus is a complication met with in some epidemics. The symptoms by which it shows itself are a great tendency to syncope, spots of purpura, and hemorrhages by the nose, bronchial tubes, stomach, intestines, and bladder. TYPHUS. 311 Imbecility, and sometimes mania (as in typhoid fever), occui' as sequels to, but not as complications of, typhus. The same remark applies to pa- ralysis, which may be general, or partial. There may be hemiplegia, para- plegia, or paralysis of the bladder, or paralysis affecting the instruments of motion or sensation, or both at once. The paralysis may also affect the or- gans of the senses-of hearing, for example, leading to deafness, which fre- quently comes on in the course of typhus, continues after convalescence, and is often associated with otorrhoea and inflammation of the external ear;-and of sight, occasioning a certain degree of amaurosis. These par- alytic affections of typhus are generally transitory, but sometimes they continue for life. Erysipelas of the face, erysipelas of the hairy scalp ; oedema of the inferior extremities, in some cases anasarca, at times dependent on renal disease; gangrenous affections of parts subjected to constant pressure, and gangrene of the limbs similar to that which we have seen in dothinenteria; coma; eruptions of furuncular or pemphigoid character; inflammations of the cel- lular tissue; parotitis; buboes;-such are the principal complications which have been described as rendering unfavorable the prognosis of typhus. The inflammatory form of typhus is characterized by the intensity of the febrile action, and acute delirium. It is most commonly met with in the young and vigorous, and chiefly among those in comfortable circumstances. The ataxic form is characterized by the predominance of nervous symptoms, such as delirium, somnolence, and subsultus tendinum. The fever is said to be adynamic, when there is great prostration, involuntary evacuations, a tendency to syncope, coldness of skin, and a slow7 pulse. It is said to be ataxo-adynamic or congestive, when the symptoms are those of congestion. Typhus has been called siderant [i. e., influenced by the stars], when it proves fatal within a few hours or days. It is said to be mild, when, as generally happens in sporadic cases, it runs through its stages without show- ing any serious symptoms. The disease is sometimes so mild, that, were it not for the presence of the characteristic eruption, one might suppose that the affection was a simple synocha. Under the name of typhisation a petites doses, Dr. Fdlix Jacquot, a French physician often quoted by Dr. Murchison, has described an aggregate of symptoms met with in persons constantly exposed to the contagion of typhus, and who are not otherwise affected by the poison. These symptoms are general discomfort, slight fever, loss of appetite, sleeplessness, occasional confusion of ideas, and a feeling of general fatigue. Real typhus sometimes declares itself in this way under the circumstances referred to; but in general, only the symptoms now enumerated occur, and they disappear on the patient leaving the poisoned atmosphere. The diagnosis of typhus presents no difficulty, when the characteristic cutaneous eruption exists. When this is absent, typhus may be confounded with dothinenteria and other diseases characterized at some periods of their course by typhic symptoms. However, independently even of this specific eruption, typhus can be distinguished from typhoid fever by an aggregate of symptoms which I shall have to bring under your notice when I discuss the question of the identity or non-identity of the two pyrexue. As to the diseases in which the occurrence of typhoid symptoms may lead to difficulty of diagnosis, an attentive observation of the phenomena will prevent mis- takes. Hitherto, gentlemen, I have said nothing regarding the researches which have been made into the temperature of typhus. I reserved my remarks on that point, that I might make them in connection with the subject of diag- nosis. Thermometrical investigation furnished valuable indications which 312 TYPHUS. enabled me to form a definite opinion in respect of a case which you had an opportunity of observing in our wards, and the particulars of which I am now going to lay before you, from notes taken clown by one of my worthy pupils, Dr. Alfred Duclos of St. Quentin.* On Saturday, 11th June, there came into my wards a man, aged 27, of good constitution, who had lived in Paris for three years and had from January last been treated for pulmonary inflammation. On the Thursday, the patient had been suddenly seized with very intense headache, rachialgia, feebleness of the legs, particularly of the right leg, in which, from that date, he complained of lancinating pains. Respiration was difficult and sighing, but he had neither cough nor haemoptysis. Ou the Wednesday, there was neither vomiting, diarrhoea, nor epistaxis. On the day of his admission into hospital-the fourth day of the fever-we found a considerable num- ber of papular spots. Next day-June 12th-the eruption was confluent on the trunk and forearms, sibilant rales were heard in the chest, and there was stupor. There was no diarrhoea. On the 13th June, the sixth day of the fever-there were vomiting, epis- taxis, and fine subcrepitant rales at the base of both lungs. Dry cupping was ordered, but by mistake the cupper scarified. On the 14th, there were stupor, delirium, subcrepitant rales, and gurgling in the right iliac fossa. The eruption was very confluent, and so great was the confluence that on the forearms, the eruption was so like that of measles, as to lead me to think that the case might be one of anomalous measles notwithstanding the symptoms of dothinenteria which existed. On the 15th, the eruption was gone, but the general condition of the patient, including the delirium and stupor, remained as before. On the 16th, the patient passed his urine involuntarily : he had no diarrhoea : but he had hemiplegia, an unusual occurrence in dothinenteria-there was a very decided want of power in the right arm and leg, as well as distortion of the features. He was cupped at the nape of the neck ; and a draught was administered containing twen- ty-five centigrammes of musk. The delirium and stupor disappeared : the patient answered with precision the questions which were addressed to him, and from that day took his full share in conversation. Two days later, he was able to leave his bed, but there was still a manifest remaining feeble- ness of the right side. He remained permanently hemiplegic, an occur- rence which sometimes follows typhus, but is never a sequel of dothinen- teria. In this case, in which I long hesitated in my diagnosis, examination of the thermal index enabled me to affirm that the disease was typhus. This is what I observed : on the fifth day of the disease, the thermometer in the evening indicated 40.4° : next day-the sixth day of the malady-there was a slight remission in the fever, and the thermometer fell to 39.8°, to rise again in the evening to the same point whence it had fallen in the morning. On the seventh day, there was a somewhat remarkable fall in the evening temperature : it had fallen to 40°, a circumstance attributable to the abstraction of blood by cupping. On the eighth day, the evening temperature was 40.6° : it fell again on the morning of the ninth day to 39.6°, rose in the evening to 40.4° ; fell one degree on the morning of the tenth day, and in place of rising six- or eight-tenths of a degree in the evening, as it had usually done, it only rose four-tenths, or in other' words, it was 39.8° on the evening of the tenth day. This remission was like the former, due to cupping. On the eleventh, twelfth, and thirteenth days, * Duclos: Quelques Recherches sur 1'etat de la Temperature dans les Maladies. Thbse Inaugurate. Paris, 1864. TYPHUS. 313 there was observed the same regularity in the evening ascent and morning descent of the pulse which had at first been observed ; but on the morning of the fourteenth day, the temperature fell abruptly to 37.2°. That is to say, between the evening of the thirteenth and the morning of the four- teenth day, within the space of a few hours, there was a fall in the tem- perature of the patient of two degrees and four-tenths. The temperature, therefore, suddenly became normal and convalescence began exactly at the end of the second week. An abrupt defervescence of this kind never occurs in dothinenteria, nor does defervescence ever take place in that fever at the end of the second week. It consequently follows, that our case was not one of dothinenteria. But the eruption, which reminded one of measles, or rather, I should say, of the measly rash of dothinenteria, might be attributed to typhus fever. Certainly the thermal changes in our patient were exactly those which occur in that disease. Here is what takes place in respect of tem- perature in typhus patients. The temperature continues to rise before the exanthematous spots come out, and for five or six days, or it may even be for ten days after it appears; this is a characteristic which at once distin- guishes typhus from the eruptive fevers. Again, in typhoid fever, defer- vescence takes place by a regularly decreasing temperature, whereas in typhus, the decline of temperature is rapid, continuous, and without evening exacerbation. By means, then, of observing the temperature in the case which I have been referring to, we were enabled at the beginning of the attack to avoid mistaking the disease for measles, and at the close for dothinenteria. My object in now describing this case is to demonstrate to you the clin- ical value of the thermometer. In conclusion let me add, that the thermal diagram is so characteristic, that Dr. Hiibler, clinical assistant of Dr. Wal- ther of Dresden, whenever he sees it, at once makes a diagnosis, even in circumstances which in this case caused me to hesitate for several days. Generally speaking, typhus is a very serious disease. According to Dr. Murchison's statistics, the average mortality in the Irish and Scottish epi- demics, has been as high as one-fifth of those seized. In London, between 1856 and 1860, a period, however, during which the cases were not numer- ous, the mortality reached the enormous proportion of forty-two in the hundred. Tn general, the mortality is greatest at the beginning and at the height, and lowest during the decline, of an epidemic. There are a certain number of other circumstances which affect the prognosis. Thus, for example, the disease is more severe in men than in women, a fact which Dr. Murchison explains by stating that typhus princi- pally attacks men debilitated by the privations incident to extreme poverty, or by intemperance. This fever is also more dangerous in adults and old people than in young subjects. It is a more serious disease among the poor than the rich. In a word, typhus is most serious when it attacks persons of enfeebled constitution. The state of the mind of the patient has an important influence on the disease. Dread of some misfortune, the fear of death, or any mental anxiety, increases the danger. A pulse above 120, nervous respiration, and the early occurrence of cerebral symptoms, are prognostics of the worst augury. All other conditions being equal, it may be said, the more profuse the exanthematous eruption and the darker its color, the greater is the danger. Even in the worst cases, however, the physician must not despair: for in no disease so often as in typhus is recovery seen to take place after the position of the patient has become apparently desperate. Recovery is sometimes abrupt: and as a general 314 TYPHUS. rale, convalescence is very rapid in typhus, a circumstance which consti- tutes a differential character between it and typhoid fever. We have now to come to the question of the identity or non-identity of typhus and typhoid fever. It is a question which has been long under dis- cussion, and is still debated. Not having had sufficient opportunities of studying typhus at the bedside of the patient, I ought, perhaps, on the plea of incompetence, to decline giving an opinion. I may, nevertheless, say that from the perusal of the works of those who have treated this subject, I have formed an opinion in unison with that of those French, English, and American physicians who maintain that the tw7o diseases are not iden- tical. Those who hold with Stokes, Magnus Huss,* and Lindwurnf that typhus fever and typhoid fever are only different forms of one and the same pyrexia, and not two distinct nosological species, still recognize the exist- ence of two absolutely distinct types, the one corresponding to our dothin- enteria,-the "typhus abdominalis" of the Germans, the "abdominal," "ileo-typhus," and "enteritic fever" of the English,-and the other being "petechial fever," the "typhus petechialis," the "typhus exanthe- maticus," or " typhus fever," characterized by a specific exanthematous eruption, very different from the rosy lenticular spots of typhoid fever, and which after a series of changes becomes petechial-the mulberry rash: this form of fever is characterized still more by the absence of the intestinal lesion peculiar to dothinenteria. Although these two forms of typhus can, in well-marked cases, be per- fectly distinguished from one another, there are, according to the physicians who believe in the identity of the two fevers, intermediate cases coming more or less near the primitive types, but blending and combining in such a way as to make it impossible to perceive sharply-marked distinctive char- acters. These mixed forms are looked upon, by the supporters of the doc- trine of identity, as the links of a chain, the two extremities of which are the two typical forms. Two principal considerations upon which is based the doctrine of the identity of typhus and typhoid fever are, that both seem to be produced by the same causes, and that during the prevalence of the same epidemic con- stitution, the two extreme forms may prevail simultaneously or predomi- nate alternately; but the doctrine chiefly rests upon the capital allega- tions that the contagion of typhus is capable of producing typhoid fever, and that also from the contagion of typhoid fever, typhus may originate. According to those by whom the doctrine of identity is maintained, the explanation of the transformations which seem to negative their views, is to be found partly in the climatological differences of countries, and partly in the hygienic conditions and diverse modes of living of different peoples. The advocates of the non-identity doctrine say, that apart from the absence of specific anatomical lesions, typhus generally presents symptoms sufficiently characteristic to distinguish it from typhoid fever. Thus, in typhus, the invasion is sudden : most of the symptoms, such as fever, stupor, and delirium appear rapidly, and with great intensity. The abdominal symptoms, such as diarrhoea, gurgling in the iliac fossa, and meteorism, are generally, nay, are almost always, absent; and when they do supervene, it is only towards the close of the attack. The total duration of typhus, as I have said on the authority of Dr. Murchison, and as you have had an * Magnus Huss: Statistique et Traitement du Typhus et de la Fievre Typhoide -Observations Recueillies a 1'hopital Seraph in de Stockholm. Paris, .1855. f Lindwukn : Du Typhus en Irlande. 1852. COMMON MEMBRANOUS SORE THROAT. 315 opportunity of seeing in the case of our patient in the clinical wards, is less than that of typhoid fever, being fourteen days in cases free from com- plication. Its favorable termination takes place more abruptly, and con- valescence proceeds more quickly, than in typhoid fever. In reply to the capital argument of their opponents, the physicians on whose side I range myself deny that the contagium of typhus can engender typhoid fever. They maintain that the having had one of these fevers does not prevent a person from taking the other, but that persons who have had either typhus or typhoid fever are found generally to have acquired immu- nity respectively from a second attack. The remarks which I made upon the treatment of typhoid fever are also applicable to the treatment of typhus. We cannot cure the disease: we cannot even shorten its course: all that we can do is to be on the watch to assist nature. I repeat to you in the words of Stokes of Dublin, that the disease cures itself. If you keep up the patient to the fourteenth, nine- teenth, or twenty-first day, he will recover. The leading indication always is to sustain the vital powers by food suited to the digestive capacity of the individual, by stimulating and tonic beverages, and by wine and spirits measured out in exact quantities. LECTURE XVII. MEMBRANOUS SORE THROAT, And in Particular Herpes of the Pharynx. [Common Membranous Sore Throat.] Many different kinds of Membranous Sore Throat might be enumerated.- Common Membranous Sore Throat often Originates in Herpes of the Pharynx.- Often Difficult, especially during an Epidemic, to form a good Differential Diagnosis between it and Diphtheritic Sore Throat.- In these Doubtful Cases we must act as if the malady were of a bad char- acter.-Recovery from Common Membranous Sore Throat is Spontaneous. Gentlemen : It is only by recognizing the existence of morbific causes, as I shall more fully show when I come to discuss the subject of specificity, that we become justified in constituting species in pathology. We could not establish species upon an acquaintance with symptoms, they being essentially changeable and fleeting, as well as common to numerous mala- dies ; nor could we base it upon lesions, although they certainly present more stable and less equivocal grounds of distinctiveness. Sometimes, indeed, a lesion seems to characterize, I had almost said to constitute, a disease: but often we cannot name any lesion as the essential characteristic of a malady. There may, on the one hand, be a complete absence of char- acteristic lesion, as when scarlatina, measles, and small-pox occur without eruption ; so, cm the other hand, we may meet in the same disease with many lesions of different kinds; as, for example, in syphilis; or again, simi- lar organic alterations may occur in the course of diseases which are essen- tially different from one another. This is what takes place in membranous sore throat. Under the exceedingly vague name of membranous sore throats [angines 316 COMMON MEMBRANOUS SORE THROAT. couenneuses] are included a number of affections possessing as a character in common plastic exudation into the pharynx. The exudation, whatever may be its cause, consists of fibrin nearly pure. In it, with the assistance of the microscope, we find small molecular corpuscles, detritus of epithelial cells, some globules of pus, and some globules of blood. These bodies vary, no doubt, in form, appearance, and consistence, but it is useless to attempt to distinguish different species of sore throat by an appeal to these varia- tions. At the same time, if we only take into account the character which these affections possess in common, we shall confound with one another maladies which are quite different in their nature. We shall, for instance, confound inflammatory sore throat with erysipelas of the pharynx, and affections, generally speaking, not at all serious, in which whitish pseudo-membranous concretions appear sometimes on the tonsils and veil of the palate, with other kinds of sore throat, which are often frightfully dangerous, and for which the name of diphtheritic sore throat has been more specially reserved. I propose to speak of the latter in future lectures. Membranous sore throat, then, constitutes a nosological genus which in- cludes many species. It is evident that it would be easy to multiply exam- ples, when we consider that mucous surfaces are not only seldom excoriated without the excoriations becoming covered with fibrinous exudations, and still more when we consider that when the inflammation of these surfaces is somewhat active, there is a remarkable tendency to the formation of plastic deposits. Thus, cauterization of the pharynx with nitrate of silver, ammonia, or hydrochloric acid, immediately excites inflammations, which are followed by the formation of pseudo-membranous deposits. These tran- sient affections may lead to a mistaken belief in the existence of diphther- itic sore throat. The effects produced by the application of cantharides to mucous mem- branes is still more remarkable, and deserves more special consideration than it receives, because cantharidic pellicular inflammation is in appear- ance similar to diphtheria: there are, however, well-marked characters by which the one affection can be distinguished from the other. As Breton- neau has said in his account of his experiments on animals, the cantharidic inflammation, limited to the surface to which the vesicant has been applied, soon becomes circumscribed and disappears, but the diphtheritic inflamma- tion extends and persists. Along with affections which, when they occupy the pharynx, constitute forms of membranous sore throat, I place mercurial, too often confounded with syphilitic membranous sore throat. In describing scarlatina, I mentioned scarlatino-membranous sore throat, and pointed out the differences between it and diphtheritic sore throat. I said then that the scarlatinous deposit has a pultaceous aspect, is less ad- herent to the tonsil which it covers, and bears less resemblance to the false membrane of diphtheria, than to the secretion from the surface of ill-con- ditioned ulcers. I believe that I dwelt sufficiently on the subject to obviate the necessity of now returning to it.* But when speaking of the complications of dothinenteria, I omitted to speak of the pultaceous sore throat which sometimes supervenes in that dis- ease. I do not refer to thrush \muguet] which, as you know, and as I shall have occasion to repeat to you, appears rather frequently as an epiphe- nomenon in the course of, and particularly at the end of, severe fevers, as well as in the wane of phthisis and other chronic diseases: I refer to pulta- * See p. 149. COMMON MEMBRANOUS SORE THROAT. 317 ceous sore throat [angine pultacee], a complication which is not very serious, but is sometimes mistaken for diphtheritic sore throat. Common membranous sore throat [angine couenneuse, dite commune] is of all the membranous affections of the throat that which has given and does give rise most frequently to errors in diagnosis. Bretonneau did not fail to perceive the nature of this affection. It is true that in his treatise on diph- theria he was not very explicit on the point, and was satisfied to mention the coincidence of common membranous sore throat with herpes, which, he says, " appears around the mouth and nasal orifices, while at the same time a membranous exudation occupies the surface of one of the tonsils." But my illustrious master often enunciated to his pupils that this common mem- branous sore throat was simply herpes of the pharynx: he compared what takes place in the mucous membrane of the mouth and pharynx with what occurs in the conjunctiva when it is the seat of herpetic eruption. This is an idea which I have often expatiated upon in my clinical lectures, both in the Necker Hospital and in this theatre: but it is to Dr. Gubler, formerly my pupil, now my colleague at the Beaujon Hospital, that the merit is due of having specially called general attention to this important subject, by the publication of his excellent memoir on herpes of the throat [herpes gut- tural]* Now that the affection has been sufficiently made known, there are few physicians who have not had opportunities of observing cases of it. A person when in enjoyment of perfect health, after a chill or some other cause, is seized with general discomfort, lassitude, and pains in the limbs, symptoms which are soon accompanied by febrile reaction. These symp- toms are of variable intensity, and are sometimes combined with disorders of the digestive canal, such as want of appetite, nausea, and vomiting. The general discomfort continues for about twenty-four or thirty hours, when all at once the patient complains of sore throat. The pain, generally limited to one side of the pharynx, sometimes (though rarely), occupying both sides, extends to that part of the cervical region which corresponds with the angle of the maxilla. There is difficulty in swallowing, a feeling of acridity and burning heat in the throat, which extends sometimes to the larynx, but oftener to the nasal fossae, and still more frequently to the Eustachian tube. The submaxillary glands are swollen, but not severely; and the amount of glandular swelling is far short of what is seen in diphtheritic sore throat, in which it is sometimes extensive. In common membranous sore throat enlargement of the glands cannot be recognized without having recourse to palpation. Care must be taken not to mistake for engorged glands the tumefied tonsils which we may come upon with our exploring fingers. If the practitioner is not called in till some time after the beginning of the affection, he will find, on examining the throat, one or sometimes both tonsils red, swollen, and covered with membranous exudation of a yellow- ish-white color, and slightly adherent to the subjacent tissues. Let me suppose, gentlemen (and the circumstances will often occur to you in practice), that you encounter this affection in a form presenting none of the lesions I am about to mention, and the presence of which would exceedingly facilitate the diagnosis-in the absence of these pathological lesions, and of precise information regarding the previous course of the disease, your first idea would be that the case was one of diphtheria. This is particularly likely to occur with children who cannot give an account of what they feel, and in whom the examination of the throat is rendered difficult by the resistance offered; in such circumstances your embarrass- ment will be great. The embarrassment is still greater both in adults and * Bulletins de la Societe de Medecine des Hopitaux; and Union Medicale, 1858. 318 COMMON MEMBRANOUS SORE THROAT. in children, when, as often occurs, the characters which distinguish diph- theritic from herpetic membranous sore throat are not unmistakably clear. As Bretonneau has justly remarked, the question can sometimes only be solved by the dangerous tendency of the diphtheritic affection to extend to the tonsils, pharynx, and respiratory passages. During an epidemic, when the diagnosis is undecided, we ought in every case to be as prompt to act as if we bad real diphtheria to combat; for-it is better to treat energetically a malady which is not serious, than to run the risk of allowing one of an essentially malignant character to gain ground. When you have obtained a history of the case from its commencement, when you have learned that an acute, burning pain in the throat was pre- ceded some days by general symptoms of illness, by febrile discomfort and disorder of the stomach, you may conclude that the case is one of common membranous sore throat; for, as a general rule, diphtheria does not an- nounce itself in that way. It, in general, begins insidiously. Hardly has the patient become a little feverish, when he complains of sore throat. Nevertheless, I hold that we cannot rest a solid diagnosis upon distinc- tions so devoid of precision. How are the membranous deposits formed ? When we are enabled to follow step by step, so to speak, the development of the pharyngeal affection, we see on the tonsils, after some time-after a few hours or two or three days from the appearance of the first general symptoms of illness-a more or less confluent eruption of red spots, which soon become excoriated. These superficial ulcerations are covered almost immediately with a gray- ish-white plastic exudation, which, spreading beyond the limits of the ulceration, may become united to ulcerations originating in other herpetic vesicles, so as to form more or less extensive membranous patches. But if, as Dr. Gubler has satisfactorily proved, this extension of the membranous deposit partly explains the formation of large membranous patches on the pharynx, it does not completely explain it: there is another cause likewise in operation. The local inflammation which has preceded, which accom- panies, and which follows the development of the herpetic vesicle, does not remain confined exactly to the original space : it extends to the surrounding parts, where it manifests itself by redness, swelling, and oedematous indu- ration : this inflammation, though not ulcerous, does not the less give rise to an exudation of plastic products similar to those secreted by the ulcerated surface. On raising this deposit, which is easily detached by using a pledget of charpie, there is found below it an ulceration more or less extensive: perhaps there may be only a small ulcerous point remaining, or the mucous membrane may be entirely cicatrized, and present no trace of the primitive lesion. When the herpetic vesicles are more apart from one another, it is easier to perceive the nature of the affection. We then see white patches, sur- rounded by a pretty extensive inflammatory areola, and varying from the size of a millet-seed to that of a pea. These spots leave in their place superficial ulcerations, which may have raised edges, the result of oedema- tous swelling of the neighboring inflamed tissues. When ulcerations of the same nature are situated in the skin, they soon become covered with a brownish crust; but nothing of this kind occurs when their seat is on the mucous membranes. The plastic exudation from the denuded surface of the dermis may be, as I have already said, in sufficient quantity to cover the ulceration and spread beyond it; or it may be so scanty as to be re- moved by the movements of deglutition as soon as it is exuded, in which case the ulcerations are very soon cicatrized, so that in point of fact no membranous deposit is formed. This is the aphthous sore throat of the COMMON MEMBRANOUS SORE THROAT. 319 English physicians, and is the only affection of this class which they de- scribe. M. Feron has considered it as a special form of the disease.* The older authors knew it: and it was probably this affection which Are tie us called benign, common ulcers of the tonsils-ulcera mitia, familiaria. But I do not wish to leave a false impression on your minds. The ex- coriations which proceed from pharyngeal herpes are very different from true aphthse of the pharynx, both in respect of their cause and manner of evolution. The aphthous affection in the mouth, or in the throat, is a rather deep ulceration, analogous to the pustule of ecthyma in the skin. It occupies an isolated situation, is exceedingly painful, lasts a long time, is easily reproduced, and is almost always associated/with a general chronic state. In a large proportion of cases, the herpetic eruption shows itself simultaneously on other parts of the cavity of the mouth, on the sides and tip of the tongue, on the internal surface of the cheeks and lips, and on the roof of the palate. There is no possible room for doubt in diagnosis, when, as is usually the case, the herpes is seen on the lips: we can then verify the similarity of the affection seen at the orifice of the mouth, by comparing it with that which occupies the pharynx, and there constitutes membranous sore throat. A case in point came under your notice: the patient was an unmarried woman, 28 years of age, who lay in bed No. 4 of our St. Bernard Ward. She had been suffering for a month from catarrh, when one morning she washed her room : she in consequence took cold, and felt very much knocked up. Next day, however, she went to her work, and continued at it during the whole day, although she felt very uncomfortable. In the evening, she had rigors and fever. On the following day, she again went to the shop where she worked: and she recollects distinctly that she had on that day a fever-spot [bouton de fievre'] on her lip. On the fourth day from that on which she washed her room, her general discomfort was so great that she had to remain in bed: she experienced a sensation of burn- ing pain in the face. On the fifth day she had violent sore throat, with a general feeling of prostration, lassitude, and pains, loss of appetite, and difficulty of breathing. Under these circumstances, she made application for admission to an hospital, at the central office : when at that office, she became sick and had copious vomiting of bilious matters. She was sent to our wards in the Hotel-Dieu. We were particularly struck with the anxiety and dyspnoea depicted on her countenance. Her voice, however, was quite natural. No morbid condition of the respiratory organs was revealed by auscultation or percussion. The sore throat was severe, deglutition was difficult, and there existed an incessant fatiguing cough. On examining the pharynx, we saw the red and swollen tonsils : the uvula also was inflamed, and glued as it were to the left pillar of the veil of the palate. The entire mucous membrane of these parts was cov- ered with whitish spots having the appearance of false membrane. There was high fever and hot skin: the pulse was 125. The patient also had gastro-intestinal symptoms, such as anorexia, ardent thirst, a bitter taste in the mouth, and constipation. The state of the patient continued very similar next day, but there was less dyspnoea and fewer membranous patches. The treatment was limited to the use of mulberry syrup gargles, and taking barley-water. She was put on low diet, and only got soups. On the eighth day from the beginning of the attack, the fever had subsided, the respiration was freer, and the local affection had to a great extent dis- * (de Lille): De 1'Angine Herpetique. Inaugurale.] Paris, 1858. 320 COMMON MEMBRANOUS SORE THROAT. appeared. There were only some whitish points on the right tonsil, the swelling of which, as well as of the other parts, was greatly diminished. Two days later, the patient left the hospital, being quite recovered. The duration of her malady was ten days. We had a young man in our wards, in whom the symptoms of the dis- ease were even more precisely characterized. In addition to the herpes on the pharynx, there was a profuse eruption of herpetic vesicles on the cheek ; and, making allowance for the diversity of aspect imparted by diversity of situation, it was impossible not to see the essential identity of the affection. Some of you, I presume, recollect this young man. He was an English domestic servant, aged 16. He came into hospital at the end of February 1868, and in five days left quite recovered. His bed was No. 1 of St. Agnes's Ward. He had just come from a long journey, during which, having been exposed to abrupt variations of temperature, he took cold. On reaching Paris on the 19th February, he only experienced great fatigue, but next morning, he had a feeling of general discomfort. During the day he had slight vomiting and rigors : he complained of pains in the head : and went to bed, where he perspired profusely. On the 21st, all of these symptoms had increased : there was ardent fever: and so great was the patient's debility that he was obliged to keep his bed. He had a great deal of headache, and he began to feel pain in the throat. At the same time, there appeared on the lip a pimple, which he called a bouton de fievre. The sore throat became rapidly worse: he had passed a bad night, and there was coryza with lachrymation. By the 23d, the pharyngeal symptoms had abated, but there was profuse salivation. A physician, who was called in, sent him to the Hotel-Dieu, after touching his throat with a solution, regarding the composition of which the patient was not able to inform us. On his admission to our wards, I observed on his face an eruption, which had come out since the morning. Several groups of vesicles, mostly of the size of a pin's head, but some a little larger, were to be seen on the right cheek, resting on a bright red base, in a line between the temple and the mouth. Some of these vesicles, presenting all the characters of herpes, were situated on the ala of the nose and on the right labial commissure : there were likewise others on the left commissure and on the chin. The herpes on the lips, however, being more advanced than that in other local- ities, was beginning to dry up. The patient complained of violent pain and annoying heat in the fape. On examining the cavity of the mouth, we detected general redness of the mucous membrane, particularly at the right side, where herpetic ves- icles were disseminated : on the tongue, also, there were some of the vesi- cles. In no situation were the redness and eruption more decided than on the isthmus of the fauces. The tonsils, red and swollen, also, the uvula and veil of the palate, likewise red, were covered with vesicles, some of which were white, semi-transparent and acuminated, others were ulcerated, and others again were covered with a fibrinous exudation, forming a layer with jagged edges extending beyond the ulcerated surface. Before us, then, we had the herpetic vesicle in its different phases of evolution. The lower part of the pharynx participated in the general redness, but exhib- ited none of the characteristic eruption. The patient suffered from pain in the throat, and an uneasy feeling which excited constant cough : the cough was guttural and painful. There was scarcely any fever, and next day, it had completely subsided. I prescribed only emollient gargles. On February 28th, the young man left the hospital, having quite recovered. He had no sore throat; and nothing remained on the face to indicate where the herpes had been, except a few red marks. COMMON MEMBRANOUS SORE THROAT. 321 I must not omit to mention some other forms of herpes affecting mucous membranes, to which Bretonneau was in the habit of calling the attention of his pupils, and which I have many times pointed out to you. I refer to herpes of the conjunctiva, and herpes of the vulva. It often happens, that when the herpes has the degree of confluence which it had in the young Englishman whose case I have just related, there is a group of vesicles on one of the eyelids : in such a case, one or two vesicles may form on the conjunctiva, or even on the cornea. When situated on the cornea, they produce an exceedingly painful keratitis, sometimes accompanied by photophobia, but which yields very easily to treatment. This form of ophthalmia is in general very imperfectly under- stood. Every one is aware that herpes of the prepuce is very common, and that it is often coincident with guttural and labial herpes ; but from the reluc- tance of women to make known such complaints, it is a less familiar fact that herpes affects the inner surface of the labia majora in the same circum- stances, and perhaps as often, as it attacks the prepuce in males. Dr. Ber- nutz, when physician to the Venereal Hospital for Women, more than once discovered herpes of the neck of the uterus, which, like guttural herpes, is often associated with fever, acute pain in the lower part of the abdomen, and leucorrhoea. This is the explanation of those attacks of transient me- tritis which we see coincident with common membranous sore throat, and which sometimes so greatly alarm women. I now return, gentlemen, to the consideration of the differential diagnosis of common membranous sore throat and diphtheria. There is no difficulty in the diagnosis, when the herpetic eruption of the pharynx is non-confluent; and the diagnosis is still more easy, when the eruption is seen on other parts of the mucous membrane of the mouth and on the lips, as it then presents itself in its own unmistakable characters. When the eruption is confluent, and when there is a pseudo-membranous exudation on the tonsils and veil of the palate, the coexistence of herpes of the lips or face will signally enlighten the physician as to the nature of the membranous sore throat he is called upon to treat, and will at the same time enable him to distinguish it from diphtheria. But when, as often occurs in practice, the membranous affection of the throat, under which the special characters of herpes have disappeared, when this membranous affection exists alone, hesitation is allowable. Although the ulcero-mem- branous lesion often assumes the particular appearance which I have just described, it is necessary for diagnostic usefulness that this appearance be quite distinctively marked, and that an opportunity has been afforded of exactly ascertaining the characters of the affection; this is especially diffi- cult in children, who submit badly to the necessary examination. It is quite true, that during the progress of the local disease, we still find, at least in some cases, numerous features of its primitive appearance; but nevertheless, at the very time when it is of importance to form an opinion, error is often unavoidable. Without being afraid of too much insisting on the point, I again repeat, that in cases in which you cannot form a decisive diagnosis between common membranous sore throat and diphtheritic sore throat, you ought to lose no time in adopting active measures, and proceed just as if you had to do with an undoubted case of malignant sore throat. Do this all the more fearlessly that (as Bretonneau justly remarks) the topical applications suited to stop diphtheritic inflammation, so far from aggravating the common membranous sore throat, shortens its duration. On the other hand, gentlemen, you must not hastily come to the con- clusion that you have a case of diphtheria, when the malady may be the VOL. I.-21 322 COMMON MEMBRANOUS SORE THROAT. milder affection : such a mistake may afterwards prove unfortunate. Grant that you have cured a certain number of your supposed cases of diphther- itic sore throat by emetics, mercurial preparations, or other remedies. En- couraged by apparent success, you will employ the same treatment when you encounter a real case of diphtheria; but then, the remedies which had seemed so efficacious will fail, and be the cause of your losing precious time which ought to have been used in contending with a disease demand- ing prompt and energetic measures. When, in the course of these clinical lectures, I shall have to speak to you of thrush [muguef], I will state the characters by which diphtheria and the common membranous sore throat can be distinguished from some affections with which they still are often confounded. When you have diagnosed with certainty herpes of the pharynx, your anxiety regarding the issue of the case is at an end. It will get well spon- taneously. The only treatment required will consist of borax or alum mouth-washes, and astringent gargles. Bear in mind, however, gentlemen, that I shall have to return to this point, and to adduce cases to show that a common membranous may become the starting-point of a malignant sore throat. Remarkable examples of the transformations to which I allude are given in the reports of epidemics of sore throat which prevailed in France during 1858. Permit me, gentlemen, to repeat to you what I said in the account which I was appointed by the commission on epidemics to read, in their name, to the Academy of Medicine at its sitting on the 22d November, 1859* The characteristic feature of the epidemics of the year 1859 was the con- comitance of common membranous and diphtheritic sore throats. Previous to the appearance of the diphtheritic affection, there was observed in many districts a marked predisposition to simple sore throat: the cases of mild sore throat, however, though only simple herpes of the pharynx, did not always present the regular symptoms usually met with in that affection. Some cases were unusually protracted in their course. In others the mem- branous affection degenerated ; and the physician had to ask himself whether he could maintain a favorable prognosis. This state of the medical consti- tution was no doubt preparatory to the advent of serious, in succession to the simple prevalent, sore throats. Not only was the one affection seen to succeed the other, but in partial epidemics, both pathological forms were observed to be more or less closely associated. Cases collected by eminent physicians, and in different parts of the Em- pire, leave no room for doubt on this point. The similarity, or rather, I may say, the identity of what was seen at the same time in different locali- ties was most remarkable: and the only difference observed was that the relation between the benignant and malignant sore throats varied accord- ing to the localities. In some places, the benignant form predominated; adults were attacked more frequently: there were fewer cases which were not mild, and deaths were exceptional occurrences. Such was the character of the epidemic in some communes in the arrondissement of Hazebrouck, and in the arron- dissement of Ma§on, where in nearly 400 cases, there were hardly 30 deaths ; in the arrondissement of Apt, where in 80 cases 4 were fatal; and in the arrondissement of Gourdon, where the mortality was 1 in the 100. In other places, on the contrary, the occurrence of the benignant form was exceptional. The patients who recovered rapidly were few in number, * Memoires de 1'Academie Imperiale de Medecine, t. xxiv, p. 31. GANGRENOUS SORE THROAT. 323 and were always adults ; but even in children, among whom the mortality was great, mortal diphtheria often began under the form of an herpetic- eruption. That happened in the communes of Vien and Thiel in the arron- dissement of Moulins; also in the departments of Charente-Inferieure, Deux- Sevres, Meuse, Nievre, Saone-et-Loire, as well as in other departments, where Drs. Castel, Dusouil, Madere, Plissard, and Guillemaut pointed out, each in his own locality, the occurrence of simple sore throat in adults, and the transformation of the herpetic eruption into characteristic diphtheritic patches, which ran their fatal course. These are the circumstances, gentlemen, in which you must with re- doubled vigilance watch your patients. These, also, are the cases in which there is not only no harm, but a great advantage-even when the herpetic nature of the sore throat is best characterized-in employing the same topi- cal treatment that is demanded by diphtheria: it will not in any degree aggravate the common membranous affection. LECTURE XVIIL GANGRENOUS SORE THROAT. Gangrenous Sore Throat from Excess of Inflammation.-Gangrenous Sore Throat Supervening as a Complication of severe Diseases such as Dysen- tery, Typhoid Fever, &c.-Gangrenous Sore Throat as a Complication of Scarlatinous and Diphtheritic Sore Throat.-Primary Gangrenous Sore Throat. Gentlemen: The considerations into which I have entered in relation to membranous sore throat are equally applicable to the affections regard- ing which I to-day propose to address some words to you. The lesion, as 1 have already told you, is not a sufficient criterion by which to establish the diagnosis, and I showed you examples of pseudo-membrane appearing in sore throats essentially different in their nature. The same remark is ap- plicable to gangrene. Gangrene of the pharynx and tonsils is indeed sometimes, though very rarely, a termination of inflammatory sore throat; it results from excess of inflammatory action. The gangrene may also occur as a complication of a sore throat of specific character ; as, for example, when it is an epiphenom- enon in scarlatina, measles, or typhoid fever, or when it supervenes in the course of any other great epidemic disease-in dysentery, for example, as seen by you in the patient who lay in bed No. 11 of St. Agnes's Ward. The patient, as you will recollect, was a young lad, who was admitted, on the 21st August, into the clinical wards, for a frightful dysentery, which re- sisted every kind of treatment by which I endeavored to subdue it. He died on the 19th October. At the autopsy, we found extensive ulcerations of the intestines, the lesions characteristic of epidemic colitis, and at many points, sphacelus of the mucous membrane. In this case, dysentery lent some of its malignity to the constitution of the patient, who, from being ex- hausted by fatigue and misery, was in a condition of all others the most unfavorable for struggling against so formidable a disease. It was during the latter days of the patient's life, that we saw the pharyngeal affection 324 GANGRENOUS SORE THROAT. come on. He complained of sore throat, and difficulty in swallowing: his voice was nasal. On examining the pharynx, we detected a dark gray patch on the right tonsil: the breath was repulsively fetid, and character- istic. The slough had the appearance of being surrounded by projecting irregular edges, and the neighboring parts were of a livid red. Cauteriza- tion with fuming hydrochloric acid did not sensibly modify the character of the gangrenous surfaces, which were excavated by very deep ulcers. The sphacelus, however, did not extend in breadth beyond the parts primarily invaded. Gangrene of the pharynx is rarely, though sometimes, met with in diph- theritic sore throat. When it occurs, it is as a complication of a pseudo- membranous affection, precisely as it occurs in scarlatino-membranous sore throat, in cutaneous diphtheria, and still more in diphtheria of the vulva, in which gangrene of the vagina is more common than in other forms of diphtheria. Again, gangrene of the pharynx often supervenes in diphtheria as the predominant anatomical element in malignant sore throat. It is preceded by the appearance on the tonsils of plastic exudations more or less thick, and covering a greater or less surface. But the spots of exudation which first appear remain limited, and gangrene soon begins: it is at first super- ficial, but afterwards, it invades and deeply destroys the tissues. Here is an example of this superficial gangrene. On Monday, 23d April, Dr. Leon Blondeau, my former chef de clinique, was called about midday to a child suffering from membranous sore throat. The patient was a boy of three and a half years of age, of good constitu- tion, who generally enjoyed excellent health. He had only been a short time resident in Paris. For about fifteen days, he had seemed out of health. He had an almost constant little cough: he was becoming thinner, and was losing the freshness of his complexion. He had been under the treatment of a physician who, having diagnosed membranous sore throat, vigorously cauterized the left tonsil with potassa fusa, there existing in that situation a whitish exudation, corresponding with swollen cervical glands. After the cauterization, he had on several occasions practiced insufflation of alum into the throat. On attentively examining the pharynx, there was seen on the left-the cauterized-tonsil, a grayish-white, pultaceous-looking de- posit, which much more resembled the plastic exudation of common mem- branous than of diphtheritic sore throat. On the right tonsil, there was a thin layer of grayish opaline substance, and three or four semi-transparent spots like the vesicles of herpes. The swollen tonsils presented a bright red appearance around the places where the plastic exudation existed: the veil of the palate and the uvula were likewise red, but showed no trace of false membrane. The child complained of pain in the throat, and had some difficulty in swallowing. The fever was moderate; and there was nothing alarming in the general condition. During the evening, a sort of thin slough became detached from the cauterized surface of the left tonsil, and the right tonsil was seen to be covered with an exudation similar to that which in the morning had covered the other: the cervical glands on the right side were swollen, and the swell- ing was greater than it had been on the left side. Both tonsils were ener- getically cauterized with the solid sulphate of copper. There was nothing particular to be seen on the uvula or veil of the palate. The voice was per- fectly clear, and quite unaltered in tone. Swallowing seemed Jo be accom- plished with some difficulty, a symptom which might arise from the pain caused by the inflammation which the cauterization had excited, and which, probably, was also the explanation of the child's repugnance to food. GANGRENOUS SORE THROAT. 325 On the Tuesday morning, there was found on the left tonsil a sort of slough, which had been observed to be partially detached on the previous evening; and on the right tonsil, there was a similar deposit, which also was becoming separated. These deposits covered superficial ulcerations of a deep red color, and the redness extended to the mucous membrane of the veil of the palate and uvula. The glandular swelling was less conspicuous than on the previous day. The general condition was not changed. Not- withstanding the difficulty which he had in swallowing, the child took some broth. Till Wednesday evening, the disease had made no progress. A portion containing chlorate of potash, which had been prescribed when the symptoms first appeared, was continued: and the necessity of nourishment was insisted on. On the Wednesday evening, the glands in the neck were very painful and a good deal more swollen, particularly on the right side, where the cellular tissue was involved. The little patient complained of pain in the right ear. There was apparently, no sensible change in the state of the pharynx. It must be stated, however, that examination of the throat was attended with extreme difficulty, in consequence of the almost insurmountable resistance offered by the child. The sudden increase of the glandular swelling was alarming. Still, the prognosis was formed under reservation, because there was no sensible change in the general state of the patient: he took food more willingly than on the previous evening, and sat up in bed to play. He passed a good night. Next morning (Thursday), the glandular swelling was found to have disappeared to a great extent. No new symp- tom was observed. By the evening, the aspect of affairs had completely changed. Although the child had asked for food, and had twice seemed to take with a certain amount of satisfaction the meat offered to it (declin- ing bread, however), there was a striking change in the physiognomy. A pale hue, a complete blanching, had taken the place of the till then natural color of the skin. The eyes were puffy; and in the mesian line of the lower lip there were two reddish-brown spots, caused by the effusion of blood under the mucous membrane. The glandular swelling in the cer- vical region, which was still greatest on the right side, had again acquired the enormous proportions of the previous evening. The veil of the palate, rising up as high as the level of the tonsils, was greatly swollen, and of a livid red color; but on bringing the nose as near as possible to the child's mouth, it was impossible to detect any characteristic odor. As the child submitted better to examination, the condition of the diseased parts was more easily ascertained. Two dark gray masses were seen floating in front of the ulcerations, from which they were detached, though still adherent to the parts by their inferior margin. When the ulcerations were touched, they yielded a mixture of blood and mucus, but at no point was there visible any trace of false membrane. The voice had preserved its natural tone ; respiration was free, but it was noisy, as in persons suffering from inflammatory sore throat. On the Friday, the condition of the child was desperate. At two in the morning, he had been seized with the most distressing restlessness and anxiety. His breathing was oppressed; his countenance had become fright- fully pale ; and his skin was covered with a cold sweat. Just as the phy- sician arrived, the agonies of death were beginning. The mental faculties, however, remained unimpaired. Respiration had that character of anxiety which it presents in malignant diseases; the inspiration was noisy, as in persons affected with oedema of the glottis. Although the voice was en- feebled, it was not altered in tone. The veil of the palate was much swollen ; its entire surface was purple-red, this color being deepest in the neighbor- 326 GANGRENOUS SORE THROAT. hood of the tonsils. There was a sanious discharge from the nostrils; but within them there was no appearance of plastic exudation, nor gangrenous spot. Such a state of matters afforded no room for a gleam of hope. Still, a large cup of coffee without milk was ordered, and a quarter of an hour after it had been taken, he was given some syrup of ether, when he took hold of the vessel and spoon presented to him. Speaking very distinctly, he complained of pain in the throat, and with his finger pointed out the situation of the swollen glands. Soon after the arrival of the physician, the child died suddenly in a faint. Although it was impossible to obtain a necroscopic examination, the de- tails of the case are sufficiently complete to leave very little room for doubt- ing that there was superficial gangrene of the pharynx. The specially remarkable circumstance to which I wish to call your attention is, that the characteristic deposits of diphtheria occupied a very small surface, and remained confined to their original localities; and so, as I formerly said, gangrene became the predominating element of the disease. Gentlemen, you will find recorded in different publications, and partic- ularly in the Gazette Medicale de Paris, and the Bulletins de la Societe An- atomique, a good many cases in which gangrene, supervening as a compli- cation of diphtheritic sore throat, had deeply destroyed the implicated tissues. Allow me to place before you the details of one of these cases, as given in a paper published by Dr. Gubler in the Archives Generales de Medecine, for May, 1857. The case is one of malignant membranous and gangrenous sore throat, complicated with diphtheria of the nasal fossae. The patient, a woman of twenty-four years of age, came into the wards of my colleague of the Beaujon Hospital on the 26th February, 1836. She had been confined four months previously; and it would appear that the infant had had the same disease as the mother. The woman stated that her child had had a hoarse cough, and had "coughed up skins," an im- portant circumstance, as Dr. Gubler justly observes. The woman had been ill for six days, at the date of her admission to the hospital. Her attack had commenced with severe pain in the throat, and great difficulty in swallowing. The submaxillary glands on the right side were engorged and painful. The symptoms did' not seem to have been ushered in by a febrile paroxysm. At his first visit, Dr. Gubler- observed that the woman could hardly speak. Her voice was snuffling, and articulation was difficult: but she was not without voice, nor was there any symptom to indicate that the larynx was involved. So great was the difficulty in deglutition, that the patient dreaded the necessity of swallowing as a punishment, though it were only the swallowing the saliva. Her mouth remained constantly half open to facilitate respiration, and give exit to the flow of saliva, and to the viscid mucus detached by the painful efforts to cough. The right submaxillary region was very swollen, hard, red, and painful. On examining the throat, a large grayish patch was seen on the right side of the isthmus of the fauces: it was easily detached by the handle of a spoon: it seemed to be a super- ficial slough of a portion of mucous membrane, of which the dermis had been previously infiltrated by plastic products. The surface exposed by the removal of the patch was ulcerated and granular: it bled freely. Both nasal fossae were equally involved, as was apparent from the snuffling char- acter of the voice, and from the respiration being exclusively performed through the mouth, A false membrane, soft in consistence, yellowish in color, and differing in appearance from the grayish patch already men- tioned, was extracted from each nasal fossa. The removal of these false membranes was followed by considerable epistaxis. Upon examining the GANGRENOUS SORE THROAT. 327 gray patches with the microscope, Dr. Gubler found that they were evi- dently sloughs of mucous membrane infiltrated by plastic exudation, and that the substances removed from the nasal fossae were undoubtedly pseudo- membranous productions. The patient was in great anxiety: she remained constantly sitting up, and her whole energies seemed concentrated in her attempts to clear her mouth from saliva and viscid mucus. Her hands, which she always had out of bed, were very cold. The pulse was weak, small, and rather quick: on the evening of the same day, it became quicker. The affected parts were cauterized with pure hydrochloric acid; and the nasal fossse were twice injected with a solution of nitrate of silver, the strength of which was forty centigrammes (6 grains) to thirty grammes (11 drachms) of water. The patient was ordered decoction of cinchona, to which coffee was added ; and there was also prescribed a julep containing two grammes of extract of cinchona. Some broth was given to her. Next day, February 27th, it was observed that the glands situated below the chin were swollen : the diphtheritic patch (or slough) extended to the anterior surface of the veil of the palate, to the right margin, the point, and left margin of the uvula: on the uvula, there remained an isolated portion of healthy mucous membrane. The difficulty of swallowing had now be- come so much aggravated as to amount to an almost complete impossibility: the glandular enlargement was very painful on pressure: the nasal fossae were more impervious than ever to air: the hands were cold, because they were always out of bed. There was a good deal of fever, and the pulse wTas 100. The use of the decoction of cinchona with coffee was continued ; and there were also prescribed a julep containing 4 grammes of chlorate of pot- ash, a mouth-wash containing 8 grammes of the same salt, and an opiated liniment for rubbing over the cervical glands. On the 28th, the general appearance of the patient was improved, and the anxiety seemed to be diminished: the pulse had fallen to 80 or 84, but it was small and sharp: the skin was cool, but not cold: the extremities had a somewhat violet color: the glandular swelling was diminished, and there was less redness and tension of the skin over the glands. There was also an amelioration in the condition of the throat, and the isthmus of the fauces was less swollen : on the right pillar, there was a very apparent loss of sub- stance : in that situation, the false membranes did not seem to have increased: the obstruction of the nasal fossae remained. The treatment, as before, was continued. On the 29th, there was a further diminution in the glandular swelling. At the lower part of the throat, sloughing surfaces were visible, and on the posterior part of the pharynx, there was a pseudo-membranous patch. On the 1st March, the patient complained of severe pains in the ears, particularly when she swallowed: she had mentioned this symptom on pre- vious days, but it had not before caused her so much suffering. These pains indicated that the specific inflammation was spreading to the Eusta- chian tubes: the hearing of the patient, nevertheless, was good: the nostrils were still obstructed, and this obstruction arose from swelling of the pituitary membrane to which the nitrate of silver had been applied. The pharyngeal surface seemed to be less coated with false membrane and pultaceous exu- dation. Between morning and evening, the pulse rose from 80 to 100. A gargle of the decoction of marshmallows and poppy-beads was substi- tuted for the chlorate of potash mouth-wash. • On the 4th, there was no longer any false membrane to be seen on the pharynx or uvula, but there was an uneven layer of it on the right pillar of the fauces. 328 GANGRENOUS SORE THROAT. Till the 6th, there did not appear to be any change in the general con- dition of the patient; but on that day, just as she was attempting to rise, she was seized with faintness and a desire to vomit. It was then observed, that there was paralysis of the veil of the palate: in drinking, the fluids were returned by the nose: the voice was very snuffling. There was, how- ever, less obstruction of the nasal fossae than formerly, and she had some power of snuffing up. She breathed freely through the right nostril, but not so well through the left. Consequent upon the administration of a purgative enema on the previous evening, she had had a little diarrhoea. She had had in the evening vomiting and epigastric pains: she described the pains as cramps and colics. Next day-the 7th-her condition became very serious : the face had a pinched look : on the eyelids, over the cheek-bones, and on the lips, there was a purplish hue: the skin of the rest of the face was of a cadaverous yellowr: the hands were livid : the tongue was pale : there was aphonia : and although there was nothing to show the existence of any pulmonary or cardiac lesion, the respiration was oppressed. The pulse had fallen almost incredibly low-to 22 beats in the minute. The patient was in a state of passive delirium, and looked as if in the algid stage of cholera. A cordial potion was prescribed. On the 8th March, at the visit, the depression of the vita] powers was as great as on the previous evening. Two days later, she died in a state of coma. In this case, as in the previous case, an autopsy could not be obtained. But you will find in the medical periodicals, particularly in the "Bulletins de la Societe Anatomique," similar cases in which were demonstrated after death, scalpel in hand, the formidable symptoms produced by sphacelus of the pharynx. You perceive then, gentlemen, that gangrene of the pharynx may super- vene as a complication of diphtheria. I have never denied that this may take place ; but I have said, and now repeat, that this complication is rare. Moreover, I am convinced that there has very often been mistaken for gangrene that which was only gangrene in appearance. I need not, how- ever, at present insist on this point, as I shall have to return to it at some length, when discussing the subject of diphtheria in future lectures. But independently of secondary, there are different kinds of primary gangrene. The rarest of them all is gangrene from excess of inflammatory action. There is also a description of gangrene, which, supervening in the course of certain- severe diseases causing profound prostration, such as dysentery, typhoid fever, small-pox, diphtheria, is a kind of primitive gan- grenous sore throat: it ought to be looked on as a distinct disease, having as its fundamental character mortification of the mucous membrane of the pharynx, which resembles gangrene of the mouth, appears suddenly, and sometimes extends to the cheeks and lips. Primitive gangrenous sore throat likewise comes on independent of any antecedent morbid influence, independent of epidemic influences which produce malignant diphtheritic sore throat: it sometimes attacks persons who seem to be in the full vigor of health, attacking them without any appreciable cause, and often causing death with a degree of rapidity, some- what variable, but never in the sudden manner in which it occurs in malig- nant diphtheria, that frightfully formidable disease of which I shall have to speak to you. This affection, however, may terminate in recovery, as I had an opportunity of observing in the case of a young man whom I saw in consultation with Dr. E. Vidal. This kind of gangrene is characterized by the presence of dark-gray GANGRENOUS SORE THROAT. 329 patches on the tonsils ; the patches are sometimes quite black, surrounded by yellow excavated edges, which are more or less elevated, when, the affection having made progress, the slough has a tendency to separate from the soft parts. When the slough has separated, whether spontaneously or in consequence of cauterization, a more or less deep ulceration is seen in its place. The gangrene may remain confined to one point; but there are other cases in which it gradually extends to the neighboring parts, invad- ing the veil of the palate, and the uvula (which it may destroy more or less completely), and taking possession of the back part of the pharynx and the aryteno-epiglottidean folds. The mucous membrane surrounding the sphacelated parts assumes a livid red color, and presents the characters of cedematous inflammation. There is a characteristic fetor exhaled with the breath : this fetor, as is natural to suppose, is greater in proportion to the extent of the lesion. The gangrenous smell has been sometimes compared to the odor of faeces. The patients complain of very acute pain in the throat, which pain is increased during deglutition. When the affection gains the veil of the palate, and even when it remains confined to the tonsil, speech is embar- rassed and the voice is snuffling. The cervical glands become implicated ; sometimes the extent of their swelling is as great as in malignant diphtheritic sore throat: and at other times there is complete absence of glandular swelling, a symptom which is never absent in diphtheritic sore throat. This disease is also recognized by the extreme severity of the general symptoms, which testify to the malignant nature of their cause, and to the general poisoning of the system. All the organic functions are greatly depressed; digestion languishes; there is loss of appetite; and the animal temperature is notably lowered : the skin of the extremities presents that livid appearance which characterizes the algid stage of cholera, and has a relation to the disordered state of the haematosis of the general circula- tion: but there is no fever. Indeed, so far from there being any fever, the pulsations of the heart and the pulse at the wrist are below the normal standard. Death is the consequence of depression of the vital powers ; and the patients either die in a state of syncope, the mind, up to the last, being not at all or very little affected ; or else they die in a state of coma. The case which I am now going to relate, occurred under my own obser- vation, and the report of it is drawn up by Dr. Millard. It will give you an idea of the symptoms which may supervene in this kind of gangrenous sore throat. The patient, M. Mancel, was the son of a Parisian physician. He was twenty-three and a half years of age, a non-resident hospital pupil, tall, strong, of good constitution, and of nervous temperament. He had com- plained for several months of frequently feeling lassitude, and of falling into fits of low7 spirits without any cause. After a slight attack of stomati- tis, he became very irritable, and from time to time was tormented with neuralgia. Under these circumstances, a perceptible change took place in his appearance ; his physiognomy became somewhat altered, and the ordi- nary paleness of his complexion was sensibly increased. On August 8th, 1853, he was seized, without any apparent cause, with rigors and a feeling of general discomfort. He could not take dinner, and went to bed. Next day, there was observed a seemingly slight inflamma- tion of the left tonsil. There was not much fever, but there was a mani- fest prostration of the whole system. Three or four days later, Dr. Mance], being alarmed at the state of his son, called in to consult with him on the case, two hospital physicians, Drs. 330 INFLAMMATORY SORE THROAT. Boucher de la Ville-Jossy and Legroux. These gentlemen could detect nothing particular in the condition of the throat; but they were struck with the fetor of the breath. On the 16th or 17th of the month, I was sent for. * I was at once struck with the gangrenous fetor of the breath. On examining the pharynx, I found a gangrenous patch on the left side of the anterior pillar of the fauces ; and the gangrene seemed to me to have a tendency to extend to the veil of the palate. I freely cauterized the parts with hydrochloric acid. On the following days, I saw the patient in consultation with MM. Andral and Nelaton. We insisted upon the necessity of an essentially tonic general treatment, embracing good soup, generous wine, and cinchona. There was almost no fever: the digestive functions were in a pretty good state: the voice was snuffling, but it was a remarkable circumstance, that there was but little difficulty in deglutition. The breath was very fetid. There was no thoracic complication. The complexion was exceedingly pale. This poor young man had, moreover, fallen into a state of great moral prostration. Some days later, a very serious symptom, double vision, manifested itself. During the night of the 27th and 28th of August, when his pulse was being felt, the patient for the first time complained of pain in the right forearm. Very soon, similar pains, then considered rheumatic, were felt in the other limbs ; but forty-eight hours aferwards, we discovered that they depended on phlebitis of the superficial veins. The pulse had now become smaller and more frequent. The gangrene of the pharynx, however, though it had not become circumscribed, had extended very little. There was no difficulty in swallowing. There was no enlargement of the glands, a circumstance to which I wish particularly to call your attention. On the 3d or 4th September we observed that the left side of the upper lip was a little swollen, and we soon perceived a double gangrenous patch on that lip and the corresponding gum. There was some puffiness of the face, and considerable alteration of the features. On the 7th September the patient was seized with delirium, which ceasing only at intervals continued till death, which occurred during the night of the 9th and 10th. LECTURE XIX. INFLAMMATORY SORE THROAT. Recovery is Spontaneous.-Distinct from Rheumatic Sore Throat.-Distinct also from the Sore Throat caused by the Secretion from the Tonsils. Gentlemen : There are some diseases which are both the glory and the opprobrium of every kind of treatment: they terminate spontaneously in recovery, but no therapeutic measures can arrest their course. Inflamma- tory sore throat belongs to this class of diseases, and to-day I propose to speak to you of a case in point which you have lately seen. The patient was a woman who lay in bed No. 1 of St. Agnes's Ward. Consequent upon a chill, she was seized with violent pain in the throat. On the first day of the attack she had no fever, but she experienced general discomfort, and the lymphatic glands on the left side of the neck were INFLAMMATORY SORE THROAT. 331 slightly swollen. Next day she was received into the Hotel-Dieu. She was then in a decidedly febrile condition. She complained of pain in the throat, and on examining the pharynx I perceived that it was of a bright red color, that there was some swelling of the left tonsil, and that on it there was a whitish patch formed by a thin layer of deposit, which, if it had not been looked at with some attention, might have been taken for diphtheritic exudation. The pains became more severe, while, at the same time, the fever increased. On the fifth day of her attack this woman had great difficulty in swallowing fluids, which, by partly passing into the larynx, caused slight paroxysms of cough. These symptoms increased in severity; and, on the sixth day, the parts implicated were more swollen, there was increased difficulty in deglutition, and an almost absolute impos- sibility of swallowing liquids, which returned by the nose. The voice was singularly modified in tone. The patient, suffering from a state of great anxiety, tormented by want of sleep and unappeasable thirst, implored me to give her relief, which it was not in my power to bestow: but I expected nature, by her own unaided powers, to afford that desired relief. And so it was: for next day the great anxiety and the pain in the throat had sub- sided as if by enchantment. The cause of all the suffering had been an abscess situated behind the veil of the palate and in the left tonsil. Instant relief had been afforded by the spontaneous opening of that abscess; and forty-eight hours after this occurrence the cure was complete. The patient had had the affection called tonsillitis, acute amygdalitis,inflam- mation of the tonsil, inflammatory sore throat, or inflammatory cynanche, using cynanche in the sense in which it was employed by the old medical authors. I prefer the latter two names, because they do not define the seat of the disease, which, as a general rule, does not occupy the tonsil itself, but the cellular tissue surrounding it. Inflammatory sore throat is, I repeat, gentlemen, one of the diseases which are at once the glory and the reproach of all kinds of medical treat- ment-the reproach, because medicine never prevails against them, in this sense, at least, that it is impotent in stopping the course or shortening the duration of the attack-and the glory, because they terminate in spontane- ous recovery whatever we do, so that there is a temptation to ascribe to medicine the honor of the natural cure. You are too well acquainted with the anatomical characters of quinsy [esquinancie~\, and its phenomena, for me to think it necessary to give you in this place a description which you will find in all your text-books. I shall, therefore, restrict myself to the statement of some general facts of practical utility. Let me point out to you that the free surface of the tonsils is very often covered with a whitish deposit, formed either by mucus or by a plastic exudation constituting a membranous patch. This deposit has a creamy, sometimes yellowish, aspect: it is not very adherent to the tonsil, not thick, and not consistent. It may deceive the eyes of less experienced observers, and suggest the idea that the affection is diphtheritic. Inflammatory sore throat, once declared, does not recede any more than an inflammation of the arm. In the latter you may sometimes usefully interpose by dividing the tissues rendered exceedingly tense by the inflam- mation, and by making incisions you will afford egress to the pus which is going to be formed: but this is not curing the inflammation, which, not- withstanding your interference, will follow not the less its natural course. It is not soin inflammatory sore throat. I know that it has been proposed, and you have read the proposal in the works which are in your hands, to scarify or cut the affected parts with lancet or bistoury: and it has been proposed to lacerate them in a more barbarous manner with Museux's for- 332 INFLAMMATORY SORE THROAT. cops, upon the supposition that the proceeding would afford relief to the patients. These methods of treatment, gentlemen, exceedingly open to objection in theory, are very little suited for practical application. I doubt whether they have ever produced the benefits expected of them ; and I have seen cases in which they were positively injurious, by increasing, in place of moderating, the violence of the irritation. Every kind of treatment has been put in requisition against this malady. For a long time the antiphlogistic method was extolled, and there are still some who proclaim its efficacy in inflammatory sore throat. Bleedings from the arm, bleedings from the feet, bleedings from the ranine vein; bleedings called derivative, accomplished by applying leeches to the neck, the anus, or the vulva; the abstraction of blood by cupping from between the shoulders or from the sides of the neck, have been vaunted as being very useful. It has even been recommended-in the true spirit of Brous- sais-to apply leeches to the interior of the pharynx; but this singular fancy will not admit of discussion. Bleeding by phlebotomy is now gener- ally abandoned in the treatment of inflammatory sore throat, but it is other- wise in respect of local depletion, for nothing is more common than to apply leeches externally over the angles of the jaw. The revulsive treatment, a term applied to the administration of emetics and purgatives, has continued longer in repute. I believe that in some cases, when there is a saburral state of the alimentary canal, the employ- ment of evacuants, particularly of ipecacuan, is indicated; but, except under such circumstances, their usefulness is very doubtful. For the third time I repeat that antiphlogistics, revulsives, topical astrin- gents, and all other kinds of treatment, are without power to impede the course of inflammatory sore throat, the naturally short duration of which nothing can curtail, and the termination of which in recovery invariably occurs. During my very long medical life 1 have never known death to occur from this malady. This fact is enough to show you how far it is from being a serious disease. At the same time, however, while I announce, and while no one will deny, its benignity, I admit that it may sometimes bring death in its train. We can understand that death may result from the propagation of inflammation from the throat to the upper part of the larynx: that inflammation reaching the neighborhood of the aryteno-epi- glottidean ligaments may lead to cedematous infiltration of these membra- nous folds; and that patients, under such circumstances, may be carried off in paroxysms of suffocation. In how many days does the malady run its course? This important question was partly answered thirty years ago by my honorable colleague, Dr. Louis.* Of twenty-three patients attacked with inflammatory sore throat, who were placed under observation, thirteen were, and ten were not, bled. The average duration of the disease was nine days in those who were bled ; it was ten days and a quarter in those who were not bled. An energetic treatment, therefore, which appeared to shorten the duration of the malady only by some hours, cannot be said to have had more than an unimportant influence. It must be stated, however, that in some cases, in- flammatory sore throat runs its course in a period much shorter than the average periods named by Louis; for the abscess sometimes opens on the fourth or fifth day. Very frequently, also, it happens, that when an amount of relief is experienced which leads to the belief that the cure is imminent, * Lours: Recherches sur les Effets de la Saigneedans quelques Maladies Inflam- matoires, &c. Paris, 1835. • INFLAMMATORY SORE THROAT. 333 the opposite side becomes inflamed, and a period longer than in the first in- stance elapses before the pus finds its exit. Acquaintance with these facts is indispensable, for they are directly appli- cable in practice. If we ignore the natural progress of diseases, we are tempted to interfere, and to interfere vigorously, in such a malady as that now under consideration, which sets in with a demonstration of such appar- ently formidable symptoms. In point of fact, inflammatory sore throat is accompanied by symptoms which regarded only in their external aspect look far more serious than those of diphtheritic sore throat. The latter makes its appearance insidiously; the disease silently makes rapid progress; and death is often imminent, when the symptoms are only beginning to alarm the family of the patient. The former, on the other hand, sets in with more disturbance. From its very beginning severe symptoms manifest themselves, but though they may all at once assume a very alarming aspect, they never become desperate. Membranous sore throats of the most terri- ble description-those which kill by general toxaemia, without the pellicular inflammation having extended to the larynx-such malignant sore throats, gentlemen, in general cause little suffering to those whom they carry off: they are much less painful than inflammatory sore throats, which, though presenting the most alarming appearances, are in reality devoid of danger. They, however, though not dangerous, cause intolerable pain, which is in- creased by the movements involved in deglutition, and is constantly being excited by the desire to swallow the saliva secreted in great abundance, or by the tickling sensation produced at the base of the tongue by the uvula enlarged in consequence of ofidematous infiltration. The pain extends to the ear, from the inflammation being propagated along the Eustachian tube: it likewise extends to the jaw-bones and lateral parts of the neck. The unhappy patient swallows with the greatest difficulty, is unable to turn his head, and frequently can neither open his mouth nor move his tongue. There is a change in the tone of his voice, and sometimes he cannot speak: the respiration is embarrassed : and suffocation seems to be impending. In addition to these symptoms, which produce a very anxious condition in the patient, there is feverish excitement: the skin is hot, the pulse is full and frequent, the face is red and congested. In some cases, delirium supervenes. A physician, who, believing that he had to do with a severe and serious disease, should deem it necessary to adopt more or less energetic treatment, would be confirmed in his erroneous belief: for he could not fail to give to his treatment the honor of a speedy cure. Let him not be in such haste to congratulate himself on his success, for very often, in place of having done good, his treatment has been mischievous. The fact is, that spontaneous recovery takes place within nine or ten, and sometimes within four or five days. As soon as the symptoms of the sore throat have disappeared, there is an immediate return to health, and all that is requisite, is to take precautionary measures, with a view to prevent a relapse. But if the patient has been ffiled at the arm, or leeched, particu- larly if he be a child or a delicate person, some time must elapse before he recovers from the exhaustion caused by the loss of blood. This consecutive anaemia will be worse than the affection which has been so uselessly com- bated : it will induce debility, loss of appetite, impaired digestion, palpita- tion of the heart, and other nervous disorders. These symptoms will continue for a month or more. I know, gentlemen, how difficult it sometimes is to remain passive when patients are waiting to receive relief at your hands; and this difficulty is all the greater in consequence of inflammatory sore throat, one of the most painful of diseases, throwing those who are suffering from it into a state of 334 INFLAMMATORY SORE THROAT. great anxiety and impatience. Nevertheless, practitioners who have before passed through similar trials resign themselves to do nothing, knowing the course which the malady will take. A friend of mine, one of the most honorable physicians of Paris, has often suffered from quinsies in the course of his life. After having treated them on all possible plans, he has for a long time been in the habit of doing nothing. Upon one occasion, when we were talking about quinsy, he said to me: " I am now very clever in the treatment of this affection : I give my patients barley-water when they are able to drink, and I prescribe foot-baths : to these measures I restrict my treatment. I do better still in my own case-if better be possible-I confine myself to my bedroom and my bed, and wait patiently; my sore throats get well quite as quickly as they used to do." One of my hospital colleagues, who also, for the last ten or twelve years, has been subject to attacks of inflammatory sore throat, has adopted the plan of doing no more than the physician whose personal experience I have just quoted. The expectant is consequently the best treatment which we can adopt in quinsy: but I admit that it is the most difficult plan to follow out in practice, particularly when the practitioner is beginning his career, and has not yet gained that confidence which he will afterwards acquire. To satisfy the justifiable impatience of your clients, prescribe for them reme- dies which are not very active. If you cannot in reality cure, you will at least be able to afford illusion to the sufferers, and will avoid disparaging yourself by an avowal of therapeutic impotence. Order acidulated sooth- ing gargles, and emollient fumigations, though all the while you know per- fectly well that they will contribute nothing to the cure of a malady which will cease spontaneously at its own appointed time. I have already said that when inflammatory sore throat has once declared itself, it never goes back : you will, however, hear some men gravely main- tain that they have cut it short during the first three days. According to them, this happy result is sometimes brought about by the use of leeches, emetics, insufflations of alum, gargles of chlorate of potash, borax, and cauterization with the nitrate of silver. Let me endeavor to explain these facts. In the first place, gentlemen, where is the physician of skill sufficient to decide whether a sore throat which has just made its appearance is cer- tain to be a quinsy? For my own part, I completely renounce all claim to ability to give a positive opinion under such circumstances, and I doubt whether others are more competent. Besides inflammation of the pharynx, there is another kind of painful sore throat,-the rheumatic sore throat. A person subject to rheumatic pains, catches cold. Some hours after- wards, he feels acute pain in the throat, pain of such a character as to pre- vent him from swallowing a drop of water or even the saliva-the degluti- tion of very small quantities of fluid occasioning much more suffering than the passage of the alimentary bolus. This is explained by the fact that to propel very small quantities of fluid towards the oesophagus, the contrac- tions of the pharynx must be more energetic than when it has to grasp a bulky body. Upon examining the affected parts,- we see that the interior of the pharynx, and the veil of the palate are more or less red : the inflamed uvula is cedematous and elongated. All the phenomena of inflammation disappear with great rapidity, they, like other affections of a rheumatic character, being in their nature of short duration. In fact, on the next or the next following day after the beginning of such a sore throat, the pain will have disappeared as if by enchantment, and at the same time DIPHTHERIA. 335 another pain will have taken possession of the neck, producing wry-neck : then, in twenty-four hours, it will be the shoulder which will be the seat of pain. Next day, the patient will complain of lumbago. As for the sore throat, its duration will have been about from thirty to forty-eight hours. If your diagnosis at the commencement of the attack was incipient inflammatory sore throat, and you have in haste used the therapeutic meas- ures at your command, you will have led yourself to believe that you have cut short an inflammatory sore throat. The physicians to whom I have just been alluding, as having boasted of causing the abortion of attacks of inflammatory sore throat, were misled by having had to do with these rheumatic sore throats. Patients who have several times had this kind of sore throat will be quite as able to distinguish it from inflammatory sore throat, as a gouty subject is to discriminate between the pain of gout and the pain of accidental arthritis : but the physician is, I repeat, unable at the beginning of an attack to decide whether a sore throat is rheumatic or inflammatory. There is another form of inflammatory sore throat, about which I see very little in classical works ; and of which I have shown you some exam- ples in the wards. In persons subject to persistent chronic inflammation of the tonsils, it often happens that the secretions from the interlobular clefts become altered in character and thickened, so as to form small, fetid, and irregularly shaped cheesy masses. These masses act as if they were foreign bodies, causing active inflammation and very acute pain : they fre- quently give rise to the issue from the tonsils of the little pointed concre- tions which you remember to have seen. The exit of these bodies is pre- ceded by acute suffering and superficial ulceration ; unless the physician, by using energetic pressure, squeeze out the small mass, so as at once to terminate a sore throat which is exceedingly painful, but far from being serious. Excision of the tonsils ought certainly to be recommended to persons very subject to this form of sore throat. LECTURE XX. DIPHTHERIA, OR MAL EGYPTIAQUE. Gentlemen : For several years past, reports sent to the Academy of Medicine, and communications to the scientific journals, have been calling attention to deadly epidemics of diphtheria in different parts of France, epidemics which have not spared the departments of the south, the centre, the north, west, or east. Similar epidemics have also been prevalent in foreign countries-in England (where for sixty years diphtheria had almost been unknown), in America, Germany, and Spain. This terrible scourge, diphtheria, has consequently of late more than ever awakened the attention of the public and of the-medical profession. In fine, the numerous cases which have recently occurred in our clinical wards put me in a position to lay before you my views on this important subject; and it is my duty to do so. I intend, therefore, in consecutive lectures, to speak of this disease, which is one of the severest scourges of humanity. I do not propose to treat the subject in an exhaustive manner : I only mean to discuss the most practical points, and to take my illustrations from cases which we 336 DIPHTHERIA. have seen together. Do not suppose, however, gentlemen, that I am going to give you complete narratives, nor even abstracts of the numerous cases of diphtheria which have been reported under your observation : while I shall make profitable application of them as we proceed with the subject, while I shall likewise support my propositions by references to my private practice, to the experience of my colleagues, and to that of different authors who have written on the disease, I shall avoid giving long histories, and quote no more details of cases than are necessary to enable you to under- stand my argument. I shall also insist, gentlemen, upon the necessity of adopting a mode of treatment, of which the utility even is at present dis- puted : I shall oppose this deplorable tendency to stray from that right path which has hitherto been followed by the best observers. Diphtheria is pre-eminently a specific disease. It is contagious. Its manifestations appear on the mucous membranes and skin; on both, it presents similar characters. I say that it declares itself on the mucous membranes and skin, because diphtheria really has that character in com- mon with specific and contagious diseases, such as the eruptive fevers and syphilis; but with this difference, however, that it does not attack the ex- ternal integument, except when denuded of epidermis. Diphtheria shows a marked preference for the pharynx, for the air-passages and particularly the larynx, constituting the affections commonly known as membranous sore throat [angine couenneusef or malignant sore throat [angine maligne], formerly designated gangrenous sore throat [mal de gorge gangreneux\ : and suffocative sore throat [angine suffocante], now more particularly called croup [croup], in which the larynx is the chief seat of the disease. Diph- theria, also, often invades the mucous membrane of the nose, mouth, vagina, prepuce, and glans penis. Of all its forms, pharyngeal, laryngeal, buccal, nasal, vaginal, anal, or cutaneous, the pharyngeal is by far the most com- mon. In some epidemics, it almost exclusively assumes the pharyngeal form, carrying off its victims by croup, the disease extending to the larynx and trachea. This is a form of diphtheria very different from that which kills by a sort of general poisoning, like septic and pestilential diseases. The attention of observers has always been more particularly directed to the pharyngeal form, because it is the most common: it is the form de- scribed by writers of bygone centuries-it is the typical form of Breton- neau's treatise on diphtheria,*-and it is with the consideration of this form that we shall commence the study on which we are now going to enter. Diphtheritic Sore Throat and Croup. [Pharyngeal and Laryn- geal Diphtheria.] Occurs in all Climates and all Seasons.- Chiefly attacks Children.-Manner in which it is Propagated.- Glandular Swellings.- The Color of the False Membranes: their Smell simulating that of Gangrene.-Its propa- gation to the Larynx.- Croup.-Intermittence of Symptoms.- Generally proves Fatal when its Progress is not Stopped. A boy four years of age, when in perfect health, was seized with sore throat, which at first was of so slight a character as not to alarm his family. After one or two days, it was observed that the boy was losing his color, * Bretonneau : Recherches sur 1'Inflammation Speciale du Tissu Muqueux et en particulier sur la Paris, 1826. DIPHTHERITIC SORE THROAT AND CROUP. 337 that he was duller than usual, and indifferent to his ordinary games. He had some cough, but no fever, and although he ate with diminished appetite, he kept up all day. It was by the merest chance that the nature of his malady was discovered. The family physician having been called in to an- other child, who was suffering from epileptic vertigo, was accidentally con- sulted. He was struck with the pale skin ; and he observed slight swelling in the submaxillary region : forthwith perceiving swollen glands, he ex- amined the throat, and found that the pharynx and tonsils were bright red, that the tonsils were enlarged, and that on the right one, there was a gray- ish, rather thick false membrane. He came to the conclusion, that the case was one of diphtheritic sore throat; and at once vigorously cauterized the affected parts with solid nitrate of silver, and detached the false mem- brane by means of the caustic. During the same evening, and on the morn- ing and evening of the following day, the cauterization was repeated. In the intervals between the applications of the nitrate of silver, insufflations with powdered alum were employed. In accordance with the express orders of the physician, the little patient got nutritious diet, and a tonic mixture the chief ingredient of which was wine of cinchona. The malady was stopped from going further: the general paleness, however, continued for some time longer, and ere long paralysis of the veil of the palate su- pervened. The child was sent to the country, whence he returned in six weeks, in perfect health. The case I have now described is one of pharyngeal diphtheritic sore throat-ordinary pharyngeal diphtheria. The insidious onset of the disease, the mildness of the general symptoms, the absence of fever at the time when the physician discovered the symptoms, the low spirits of the child, the paleness of the skin, the swelling of the submaxillary glands, and the presence on the right tonsil of the characteristic pseudo-membran- ous exudation superabundantly justified the prompt diagnosis. The pa- ralysis of the veil of the palate which supervened some days later, still further confirmed it; and I have no doubt that the energetic treatment which was employed from the very first, cut short the disease, which might under other circumstances have gradually extended, got possession of the larynx, and produced croup. This pharyngeal diphtheritic sore throat is met with in all seasons and in all climates. Not without a certain degree of surprise, I have some- where read that this disease is chiefly observed in northern countries and in cold moist climates, while it is almost unknown in the south of France and in Italy. The person who put forth this singular opinion* must have had a very imperfect acquaintance with the history of medicine, not to know that the disease was described by Aretjeus ; that it is just membranous sore throat; that it was endemic in Egypt and Syria, having from that circum- stance received its names of Egyptian and Syrian ulcer, names which, as is stated by Bretonneau, were given to it in the epoch of Homer rather than of Hippocrates. He must, I would farther remark, have been imperfectly acquainted with the history of medicine, not to have known that Carnevale, Nola, and Sgambati have left us accounts of epidemics of morbus strangu- latorius which prevailed in Italy at the beginning of the seventeenth cen- tury, when similar epidemics were observed in Spain by Villareal, Fontecha, Nunez, Herrea, De Heredia, Mercatus, and Tamajo. At the present day, * An exactly opposite statement was made by Wedel, an author of the last cen- tury, who stated that diphtheritic sore throat, which he called angina infantilis con- tagiosa, was more frequent in Italy than in the north of Europe: "in Italia frequentior quam apud Boreales Europoeas." [De morb. infant., cap. xx, p. 77.] vol. i.-22 338 DIPHTHERIA. throughout all France, as I have said, we still meet with similar desolating epidemics of this kind of sore throat. Diphtheria spares no particular age: it chiefly, however, attacks young subjects, and generally those who are between three and six years old. It begins with a more or less decided redness of the pharynx, with swell- ing generally of one, but sometimes of both tonsils. Soon afterwards, there is seen on the affected part a sharply defined whitish patch, at first formed by a layer of what looks like coagulated mucus; it is semi-transparent, grows concrete and thick, and very soon assumes a membranous consistence. This exudation, immediately after its formation, is easily detached, as it only adheres to the surface on which it rests by very slender filaments ex- tending into the muciparous follicles. The mucous membrane under the patch is perfectly healthy, even close to where the epithelium is destroyed : if it sometimes has an appearance of being hollowed out, this arises from its being swollen around the exudation, so as to form a sort of cushion with a hole in the middle. The occurrence of ulceration is exceptional. Generally, I repeat, the mucous membrane is healthy, or it presents no other change than an increased vascularity. On cautiously detaching the false membrane, there is not the slightest oozing of blood: it can, moreover, be often shown, with the aid of the microscope, that, on its surface which adhered to the mucous membrane, the epithelium remains with its vibratory cilia intact. Some hours later, the pseudo-membrane, more prominent, convex towards its centre, and thin at its edges, has increased in size, and covers more of the tonsil: it has now assumed a yellowish-white color, and is becoming more and more adherent to the parts first affected. The color may vary from yellowish-white to deep yellow, or even to gray or black. Generally, when the veil of the palate begins to be inflamed, the uvula becomes swollen: after some hours or a day, the side of the uvula next the tonsil which is covered with false membrane, becomes covered with a similarly colored exudation. Often, within twenty-four or thirty-six hours, the entire uvula is enveloped like a gloved finger. At the same time, upon the other tonsil, a similar patch has appeared, and will soon cover it. The back part of the pharynx, thus commencing to be as it were carpeted on both sides, by and by exhibits long, narrow, longitudinal striae of a deep red color, amid which forms a little band of concrete matter; and then patches of false membrane appear, which finally unite with one another. From this time, if the child be docile, submitting easily to the examination required, and allowing the tongue to be quite depressed, a view is obtained of the uvula, both pillars of the veil of the palate, both tonsils, and the back of the pharynx com- pletely covered with the coating which I have described. When an attempt is made to detach these false membranes with forceps, they can be torn off in strips: in this way I have removed from the uvula a pseudo-membranous envelope shaped like a thimble. Generally, from the very beginning of the attack, the lymphatic glands at the angle of the jaw, those, therefore, which correspond with the first affected tonsil, are turgid. This, gentlemen, is an almost invariable phe- nomenon, or at least, it is not wanting once in ten times. Its importance, therefore, is great, and all the greater, that in common membranous sore throat, a malady generally mild, but liable to be mistaken for that now under consideration, this glandular engorgement is entirely absent, or, if it exist at all, is present in a much less degree than in pharyngeal diphtheria. At the invasion of the disease the fever is pretty high, but after the second day it begins to subside, and by the third or fourth day has quite disappeared; the patient then only experiences in a slight degree feelings DIPHTHERITIC SORE THROAT AND CROUP. 339 of general discomfort, as indicated by prostration, low spirits, and a certain amount of weakness. Sometimes, the only thing of which he complains is a difficulty, often very slight, in swallowing; so that, in general, at the beginning of the attack, there is nothing to occasion much alarm. When left to itself, the affection generally remains from three to six days confined to the pharynx. The older the subject, the. longer is the disease in becoming developed by progressively invading the parts accessible to sight. False membranes form more rapidly in children than in adults, from the greater plasticity of the blood in the former. In children be- tween three and six years of age, both tonsils and the posterior part of the pharynx may be coated with diphtheritic exudation in about thirty-six or forty-eight hours, whereas in adults, and still more in old people, from five to eight days may elapse before all the parts are invaded. In patients who allow a thorough examination of the pharynx to be made, the false membranes can from day to day be seen to grow thicker by the addition of the new layers which form below those first formed : these different deposits assume a stratified arrangement. The pseudo-membran- ous layers which are most superficial become soft, and are easily torn. The membranous patches, altered in color by the alimentary substances, drinks, and medicines taken by the patient, by matters vomited, or by blood from the pharynx and posterior nares, become grayish or blackish, so as to resemble a gangrenous slough. Under these circumstances, the false membranes are the more liable to be mistaken for gangrenous sloughs, that they become putrid, and exhale a disgustingly fetid odor. This, gentlemen, as you will recollect, is what took place in a girl twelve years of age, who was lately under our observation in St. Bernard's Ward. Her breath had an intolerably gangrenous smell, and when with the assistance of a dossil of lint, I removed the detritus covering the tonsils and veil of the palate, I found that it consisted of a grayish matter which exactly simulated gangrenous detritus; but so far from being gangrenous detritus, when the mucous membrane of the affected parts were wiped, that is to say, the mucous surface which had been covered with this detritus, it appeared red, hardly excoriated, and certainly presenting no trace whatever of gan- grene. The resemblance to gangrene which invests the diphtheritic product is a point of sufficient importance in relation to the question before us to justify me in pausing for a few minutes to consider it. It explains to us why diph- theritic was for so long confounded with gangrenous sore throat, and why it got the names of " angine" and " mal de gorge gangreneux," still applied to it by many physicians. In studying diphtheritic sore throat in the child, and comparing it with the disease as seen in the adult, it is found that in the former it has very seldom, and in the latter very commonly, a gangrenous aspect. Are we to conclude from this fact that gangrene really exists in the diphtheria of adults? No: its existence is only apparent; true gangrene, except in ex- tremely rare cases, is not met with in the diphtheria of adults more than in the diphtheria of children: in my whole medical career, I have only met with three such cases. I readily grant, however, that such statements do not easily obtain credence. Even now, although I have ascertained that gangrene is an exceedingly rare occurrence in diphtheria, although I know perfectly well that at the termination of the case, whether the issue be re- covery or death, I shall be able to demonstrate, either on the living subject or on the dead body, as the case may be, that the mucous membrane is devoid of even the slightest trace of sphacelus; although I know that I shall find only in some cases a few small excoriations, I am still, at the first 340 DIPHTHERIA. glance, unable to shut out completely the idea of gangrene. In the young girl, our patient in St. Bernard's Ward, I was perfectly certain that this gangrene did not exist, and you, too, held with confidence the same opinion ; nevertheless, struck with the horrible fetor of the breath, and seeing the grayish flesh-like pulp which covered both tonsils, we could not prevent ourselves from thinking of mortification of the mucous membrane, sphacelus of the subjacent cellular tissue, and a still deeper destruction of parts. Thus, gentlemen, you can understand how diphtheritic has been confounded with gangrenous sore throat: thus, also, you can understand how some physicians still confound the two diseases, and why, in the accounts of epidemics of croup, there is such frequent mention of gangrenous sore throat, when in reality the affection is pellicular or pseudo-membranous. Let me add a few words on the manner in which the membranous exu- dations are circumscribed in the situations in which they are formed. Sometimes, they are surrounded by a bright red border : at other times, they seem not to be encircled, and thus, as I told you, at the commence- ment of the lecture, the pseudo-membranous deposit becoming thinner at the edges, shows itself on the neighboring parts. In the latter case, we have more cause to dread the disease spreading than in the former. It is true that pharyngeal diphtheria if left to itself may remain confined to the pharynx, and Bretonneau himself has cited examples of this, which indeed is not uncommon in some epidemics; but generally, it extends, when preventive measures are not employed. In some cases, it reaches the oesophagus, and even proceeds to the cardiac orifice of the stomach. The illustrious physician of Tours has recorded two examples of this, and simi- lar cases have also been mentioned by Borsieri: almost invariably, how- ever, it invades the larynx and trachea, constituting what is called croup. Such is the usual course, and most common termination of diphtheria. In point of fact, we see many more of those who are attacked by this disease die from croup than from malignant sore throat, of which I shall afterwards have to speak, which proves fatal after the manner of septic diseases. The propagation of the diphtheritic affection to the larynx was long ago fully recognized. Aretseus has described it in his chapter " De Tonsil- larum Ulceribus," where you will find the earliest notice of membranous sore throat: he speaks of it under the designation of ulcera pestifera, and refers to the names " Egyptian" and "Syrian Ulcer," by which it was then designated. Read in the annals of medicine the histories of epidemics which are therein recorded, and you will see that not only was the exten- sion of the disease to' the larynx perfectly well known, but was a subject which specially engaged the attention of physicians. By whatever name the laryngo-tracheal affection is called, it is almost universally recognized as the cause of death. It is then, I repeat, by croup that the victims of laryngeal diphtheria are killed. I am not at present speaking only of sporadic, but also of epidemic diphtheria. Such are the symptoms of the affection which, in the seventeenth cen- tury, was called garrotillo by the Spaniards, and male in canna by the Italians. The name given to it by the Spanish and Italian physicians was morbus strangulatorius: the Americans called it suffocative sore throat at the close of last century, and it is at present known to us by the Scottish name, croup. You have had, gentlemen, only too many opportunities of seeing the laryngeal symptoms in patients brought into the hospital at different stages of the disease. You had once an opportunity of observing their commence- ment. The subject of the case to which I refer was a boy of eighteen months. DIPHTHERITIC SORE THROAT AND CROUP. 341 He came into the Hotel-Dieu along with his mother. Both were affected with very confluent sudoral eruptions, but were not otherwise out of health. Six days, however, after their arrival in our wards (wtfere there was a child with croup and a woman with pseudo-membranous sore throat), the mother complained of sore throat. On examination, we found the right tonsil and the uvula coated with false membrane, and the cervical glands enlarged. I immediately cauterized the affected parts with hydrochloric acid: next day, the membranous deposit had almost disappeared, but in twenty-four hours it was reproduced in greater abundance, and in a thicker layer than at first, upon the uvula as well as upon both tonsils. The cau- terization was repeated, and it was practiced again on the following day, although an appreciable amelioration was noted, and which did not turn out deceptive. This patient recovered. Her child, however, was attacked three days after her own seizure. In the child we observed a thick, whitish concretion upon the right commis- sure of the lips, which was slightly excoriated. I cauterized the part: and, taking into account the age of the subject, I told you that danger was im- pending. On the second day, the diphtheria had taken possession of both commis- sures : but the tonsils as well as pillars and veil of the palate presented nothing abnormal, not even redness. On the following day, there was a diminution in the thickness of the false membranes on the lips; but it appeared to me that the child's voice was becoming hoarse. When my chef de clinique, Dr. Moynier, made his evening visit, he observed hoarse- ness and a cough which had a hissing character : the voice was muffled. The patient had had fits of suffocation during the day. The disease had in no degree extended to the tonsils or palate. An emetic was prescribed. When I saw the patient fourteen or fifteen hours later, I learned that the suffocative attacks had become so violent and so frequent that tracheotomy had been deemed necessary. The operation was performed by the interne on duty. At the moment of opening the trachea, a false membrane was expelled. I found the child free from fever, and the neck much swollen : it died during the day. On the morning of the day on which it died, I detected the presence of pneumonia of the right lung, characterized by a blowing sound, dulness on percussion, and oppressed breathing. At the autopsy, we did not find any deposit on the tonsils or veil of the palate, but the larynx and trachea were invaded by false membrane, which extended even to the most distant bronchial ramifications. The character- istic lesions of pneumonia were found throughout the whole of the lower lobe of the right lung, as well as disseminated in several parts of both lungs. The presence of croup is first announced by a small dry cough, which comes in quickly succeeding fits of short duration. The voice, up to this time unaffected, now becomes a little changed, and, like the cough, has a special character, with which it is important to be acquainted : it does not admit of description, but can never be forgotten once it has been observed. The cough is not sonorous and loud, but on the contrary is hoarse, muf- fled, and has a sound which may be compared to the distant barking of a puppy. The term croupy [croupale] conveys a false impression, and is much more applicable to the cough of laryngismus stridulus or false croup. The cough is at first very frequent, but it generally loses that characteristic as the disease advances. After a short time, the breathing is affected. The difficulty of breathing occurs at an earlier period in children than in adults. It usually begins during the night; and there is produced at the same time a laryngo-tracheal 342 DIPHTHERIA. whistling sound at each inspiration, which is also, but less audibly, heard during expiration. This whistling sound is best marked after each fit of coughing: it is Caused by an inspiration, short, dry, and metallic-sounding, which can be quite well heard at some distance. On auscultating the trachea and posterior part of the chest, this sound strikes so strongly on the ear as to mask the murmur of the vesicular expansion. The causation of this laryngo-tracheal whistling is explained by the mechanism of the vocal apparatus. The sound is louder during inspiration, because the lips of the glottis have then a tendency to approach each other, thus increasing the difficulty of the entrance of the air, whilst, on the contrary, during expira- tion, the lips tend to separate. Generally, the pain felt in the larynx is not severe, but it is excited by the fits of coughing: it is not confined to the larynx, but extends to the trachea and anterior part of the sternum. The disease goes on increasing in severity, the false membranes extend- ing and thickening: the cough, however, goes on diminishing in frequency, the fits occurring only at intervals of a quarter of an hour, half an hour, or even longer: it also loses some or all of its hoarseness. The voice itself, which had a hoarse and somewhat metallic sound, in its turn fails, and the patient often becomes voiceless. Aretaeus said : vox nihil significat. The symptoms which generally accompany difficulty of breathing in pseudo- membranous laryngitis are evidence of the presence of diphtheritic deposit on the lips of the glottis. You can see at once why this should be so. You are aware that a little mucus adherent to the vocal cords is sufficient to change the tone of the voice, to make it hoarse, and sometimes even to occasion aphonia. It is not surprising, then, that the formation of false membrane on the lips of the glottis should be a still more decided cause of loss of voice. What occurs is exactly what takes place when you place a piece of wet parchment between the reeds of a clarinet or bassoon: the cor- rectness of this comparison is enhanced by the great similarity which false membrane bears to parchment swollen from being wet. The reeded instru- ment constituted by the larynx is in this way made unfit to perform its part: the voice and the cough become more and more changed as the de- posit increases on the vocal cords, and at last they both cease. This is a physical phenomenon which is perfectly explained by the arrangement of the parts concerned. On some rare occasions it happens that the hoarse cough returns, and that the metallic voice is again heard in consequence of violent expiratory efforts having occasioned the detachment and expectora- tion of the false membrane; or, it may be that the false membrane which coats the glottis is so thin as not to prevent the air from vibrating as it traverses the larynx. Speaking generally, it may be said that the cough, at first croupy, becomes less and less sonorous. I have said that difficulty of respiration supervenes in the infant after the lapse of a very short time, and that it likewise occurs in the adult, but not at so early a stage; this symptom rapidly increases in severity. There then sometimes occurs a phenomenon to which I must call your attention, because it may mislead you as to the nature of the disease, or at least in- duce you to put faith in the efficacy of the treatment which you have em- ployed. Although the laryngeal lesion continues, although there is a per- manent mechanical obstacle to the passage of air, although the false mem- brane which occasions this obstacle remains adherent to the vocal cords, the difficulty of breathing is intermittent. A child or an adult may have during the day several fits of dyspnoea, proceeding even to suffocation. During the intervals between the fits, if the patient is not agitated by the presence of the physician or any other cause, if nothing occurs to quicken respiration, it is nearly as regular as in a person in health, and no laryngeal DIPHTHERITIC SORE THROAT AND CROUP. 343 whistling is audible. But from time to time, at first, every hour or every two or three hours, and then at shorter and shortening intervals, a suffoca- tive fit conies on without any immediately exciting cause. The patient sits up, and sometimes gets up abruptly, to search, out of bed, for that air in which he stands in need. He makes immense efforts to breathe, throwing back the head, opening wide the mouth, and convulsively contracting all the muscles which co-operate in respiration. The suffocative fit, which lasts from four to six minutes, is succeeded by a calm which lasts for a certain time. These facts, pointed out by Royer-Collard,* and B retonneau, f did not escape the observation of our predecessors. I cannot resist quoting to you the words of Borsieri, who had specially devoted to this subject a paragraph of his chapter on croup. It is entitled " Fallax morbi mitigatio;" and is to the following effect: " Animadvertendum quoque est non raro et subitd praeter rationem, et sine ulla materice obstruentis excretione omnia sic in melius verti, ut liberior, imo naturalis omnind respiratio reddatur, ut infantes puerive e lecto surgere et obambulare possint: pauld post verb fallaci bine symptomatum quieti novum repente succedere insultum, saepe numero gravem." This intermittence in the suffocative symptoms has been justly attributed to a spasmodic stricture of the glottis, caused by the inflammation of the mucous membrane of the air-passage, or by the presence of the plastic lymph poured out into its cavity: it may also depend upon a combination of both these causes. This is the opinion of Nieusseux, of Albers of Bre- men, of Jurine, and of the members of the Academy commissioned to report on the papers submitted in the competitive examination of 1812. Farther, the commission, adopting the views of Albers of Bremen, said that the pseudo-membranous deposit sometimes formed a purely mechanical obstacle to the entrance of air into the bronchial tubes; that most commonly it was spasm alone which, by narrowing the air-passage, stopped and impeded respiration. Bretonneau disputes the accuracy of this explanation: accord- ing to him, the mechanical obstacle occasioned by the formation of false membrane explains everything. " As to the intermissions," he says, "they belong to a numerous class of pathological phenomena. Where is the prac- titioner who has not observed them? Is not the pain of cancer, stone, and other diseases intermittent, though its cause is permanent ?" Though the element spasm does not in my opinion hold the important place assigned to it by some in croup, it yet, I think, plays a very important part in this affection, as well as in the chronic diseases which my illustrious master uses as illustrative examples in his sentences just quoted. From the importance of this subject, I shall afterwards return to it: and I shall specially have occasion to revert to it, when I speak of symptomatic affections of the ner- vous system, particularly of angina pectoris and asthma. To continue the description : The suffocative attacks follow one another more rapidly, and at the same time become more and more violent: very soon there is no interval at all, the suffocative struggle being continuous up to the agony of death: the laryngeal sound also becomes permanent. From time to time, the poor children, in a state of excitement which it is impossi- ble to describe, suddenly sit up, seize their bed curtains and tear them with convulsive frenzy: they sometimes strip off the paper from the wall with their nails : they throw themselves on the necks of their mothers or of those about them, embracing them and trying to clutch whatever they can as a * Royer-Collard : Dictionnaire des Sciences Medicales, f Bretonneau : Traite de la Diphtherite. 344 DIPHTHERIA. something to hold by. At other times, it is against themselves that they direct their impotent efforts, grasping violently the front of the neck, as if to tear out from it something which was suffocating them. The puffy, pur- ple face, and the haggard sparkling eyes express the most painful anxiety and the most profound terror: the exhausted infant then falls into a sort of stupor, during which respiration is difficult and hissing. The face and lips are pale, and the eyes sunken. At last, after a supreme effort to breathe, the agonies of death begin, and the struggle ends without there having been any severe suffocative symptoms such as might have been looked for from the previous attacks. In adults, the picture is still more frightful. The violence of the suffo- cative attacks, the sort of frenzy which takes possession of the dying sub- ject, vainly struggling to get rid of the obstacle to respiration, it is impos- sible to depict. At last, when the lips have become livid and the face turgid, when asphyxia has reached its last stage, the adult, like the child, falls into a state of stupor, and dies generally in a state of prostration. To use Borsieri's words: "Sic irrequieti assidue jactantur, donee penitus pros- trati jaceant et strangulati pereant." I say generally, because in some ex- ceptional cases the patient is carried off by a fit of suffocation. As I have already remarked, the intermittence of the suffocative fits is a fact very important to be acquainted with, inasmuch as ignorance of it might lead you into error. Suppose, for example, that having been called in to a case of croup, you resorted to some particular treatment, that you applied leeches, abstracted blood from the arm or foot, gave an emetic, or applied a blister to the front of the neck or to the chest; and suppose further, that immediately after you bad done one or more of these things, there oc- curred one of those intervals of calm of which I have spoken, you might ascribe this to the efficiency of your treatment, while, nevertheless, the dis- ease had only followed its natural course. It is important, therefore, to be aware of the fact, that, independent of treatment, the suffocative fits are in- termittent. Besides intermittence depending upon the element of spasm entering into the case, there is also intermittence arising from expulsion of the false membrane which causes the suffocative attacks. It happens sometimes-once, perhaps, in six or eight times-that in a paroxysm of vomiting or cough, the larynx is all at once cleaned, the child or adult discharging strips of false membrane or membranous tubes, which come from the glottis and windpipe. When this occurs, there is all at once as complete quietude as if tracheotomy had been performed. The patient falls into a tranquil sleep, and may remain quiet for six, eight, ten, fifteen, or twenty-four hours. The relations then entertain hopes of recovery, in which the physician even is tempted to participate. He, however, cannot lose sight of the fact that diphtheria is a disease, which, though it occasion- ally grants a respite, does not as readily bestow a pardon. He cannot for- get that when a false membrane is detached from the larynx or trachea, another begins to form in its place: that the exudation, passing anew through its stages, again covers the parts with a layer which at first thin, gradually becomes thick, and so at last re-establishes the obstacle which formerly existed. Suffocative attacks, similar to those which formerly occurred, will take place, and if, as before, the new diphtheritic deposit should be expelled, there will always be a fear of its again forming. I have seen children ex- pel three or four successive pseudo-membranous formations, and sink at last from the disease. However, I must also add, that I have seen in a few rare cases, ultimate recovery after the spontaneous expulsion of false membranes. But so exceptional and rare are such cases, that during the DIPHTHERITIC SORE THROAT AND CROUP. 345 whole of my long professional career, I have only met with six, though the number of cases of croup, both in adults and children, which I have seen, is great. It is a remarkable fact, that although the expulsion of the false mem- branes undoubtedly offers favorable chances of recovery to the patient, they are less favorable when, recovery not having taken place spontaneously, one is forced at a later stage to resort to tracheotomy. In other words, the operation will be less likely to succeed in a child who has discharged false membranes, than in one who has not: you will at once perceive the reason of this. The presence of pseudo-membranous products in the larynx and trachea show, that the diphtheritic inflammation has reached them. After tracheot- omy, the extension of the inflammation seems to cease. The expulsion of diphtheritic products, by retarding the crisis at which operative interference becomes imperative, allows the inflammation to extend in such a way, that in a child who has got rid of pseudo-membranous tubes, whether by the efforts of coughing or and who has in consequence experienced temporary amendment and in whom the necessity for operating has b/?en thereby postponed for forty-eight hours, you run the risk of having the bronchial tubes invaded with false membranes, even to their remote rami- fications ; whereas, in another who has had at the beginning tracheotomy performed, followed by expulsion of false membranes, this state of matters will be rarely found. I have already said that in rare cases-cases, however, which are not so rare as is commonly believed-the disease in place of pursuing its usual progress from the pharynx to the larynx and trachea, follows the opposite course, and attacking in the first instance the trachea, or beginning even in the bronchial tubes, ascends to the larynx. Finally, diphtheria, declaring itself simultaneously in different situations, may at the first onset of the disease exist in the interior of the larynx, trachea, and bronchial tubes, while it is also manifested in parts accessible to sight. This is what took place in the little boy of St. Bernard's Ward, of whose case I have just been speaking. I will now relate another similar case which occurred in the Children's Hospital, and was reported by Dr. Leon Blondeau during his internal there under Dr. M. P. Guersant. A little boy of three and a half was admitted on the 9th of November, 1847, to the Hospital in the Rue de Sevres, presentingall the characteristic symptoms of croup. On Saturday, 30th of October, he had been seized with fever: on the Tuesday following, the eruption of measles was observed: it was of moderate intensity, but the morbillous catarrh was very severe. On the Saturday, and still more on the Sunday, attention was drawn to a decided embarrassment in the breathing, and a hoarseness in the voice, both of which progressively increased. When the child was brought to the hospital, the following symptoms were observed. The face was pale, and of a livid tint. There was considerable dyspnoea. The nasal fossae were obstructed by a thick grayish mucus; but on carefully examining the throat, no appearance of false membrane could be detected. The patient was made to vomit, but not even temporary amendment resulted from this proceeding. The excitement and oppression were extreme. The pulse was 120 in the minute. On auscultating the chest, sonorous rhonchi were heard. The presence of exudations, evidently diphtheritic, in the nasal fossae, having led to the idea that possibly there were false membranes behind the veil of the palate, an attempt was made to introduce into that situation a hair pencil charged with a strong solution of nitrate of silver. This pro- 346 DIPHTHERIA. ceeding greatly increased the excitement. It is worthy of notice that in this case, there was never any enlargement of the submaxillary glands, a fact explained by the absence of pharyngeal lesion. Another emetic was prescribed-five centigrammes (between four and five-sevenths of a grain) of tartar emetic. On the 19th of November, the child was more tranquil, and the dyspnoea was slight; but the cough was hoarse, the voice gone, the countenance livid, and the deposit in the nasal fossae persistent. The pulse was 128, small, and thready. By the evening, there had been no vomiting; but the child had had ten green stools. The breathing had again become very oppressed, and the respirations were 46 in the minute. The child was in a state of orthop- noea. The voice was entirely gone: expiration was not, but inspiration was, noisy, and sounded as if something were impeding it: the cough was very hoarse. The nose and ears were cold : the livid hue of the counte- nance was increasing, and the eyes (generally closed) had a very languid expression. The poor child was constantly moving its head from side to side, as if in search of a position. But it sgon fell into a state of collapse arising from asphyxia, and increased by the debility occasioned by the numerous alvine evacuations which had taken place during the day. Con- sciousness was unimpaired. During the night, two violent suffocative fits occurred: next day, the asphyxia was greater than it had been in the evening. The face was pale and puffy : the lips were cold and colorless. The mind, however, seemed quite clear, the child expressing by signs that he wished to drink. He swallowed easily. Death occurred during the day, without any attempt having been made to perform tracheotomy, which from the course taken by the disease would have been useless. At the autopsy, the respiratory passages of both lungs were found lined with false membrane from the larynx to the first ramifications of the bron- chial tubes ; and below that, the tubes were filled with thick mucus. In the nasal fossae, were found the exudative products which had been seen during life: but neither in the pharynx nor mouth was there anything which could correctly be called false membrane. In conclusion, to repeat what I have just been saying-and the point is of sufficient importance to justify my recurring to it-although the expul- sion of the false membranes may in a few cases lead to the spontaneous cure of croup, it is certain that when the disease has followed its usual down- ward course, the chances of a successful result from tracheotomy is much less when membranous tubes have been expelled, inasmuch as that is evi- dence of the disease having extended to the ramifications of the bronchial tubes. This extension of the disease sometimes proceeds very far, and I have seen cases in which children have, after tracheotomy, brought up false membrane moulded in the very minute bronchial ramifications. I still have in my museum one of these arborizations of false membranes, which I have shown you, and which was obtained under your own observation at the autopsy of a little girl who died in our St. Bernard's Ward. This diph- theritic arborization, comprising the trachea and the large tubes, extended to the fourth ramifications. I met with a similar case, in a child of five years of age, who was cured by tracheotomy. The false membrane was expelled at the time of the operation. It must be stated that generally, in two-thirds of the cases according to the statistics collected by Bretonneau, as well as according to those of Dr. Hussenot,* the false membranes do not extend below the trachea. * Hussenot : These Inaugurale, soutenue en 1830. DIPHTHERITIC SORE THROAT AND CROUP. 347 This is a remarkable fact, and, as I shall afterwards have to remind you, has a bearing favorable to resorting to tracheotomy in this disease. It appears, however, that in some epidemics, the extension of the membran- ous formations to the bronchial tubes is more usual and more rapid than in the epidemics which have come under my observation. Dr. Peter, who had an opportunity of studying a severe epidemic of diphtheria at the Children's Hospital, in discussing my opinions on this subject, thus expresses himself: " Dr. Trousseau describes with care the different localizations of diph- theria : nevertheless, my own observations justify me in believing that bronchial diphtheria is more frequent than the clinical professor supposes, for I have noted it as occurring in nearly half the cases-54 times in 121 cases. I can also affirm that diphtheria extends with incredible rapidity to the bronchial tubes, a fact, till now, far from being known. In four days, a considerable surface of the bronchial mucous membrane may be coated with false membrane; and it is generally between the second and fourth days inclusive, that the bronchial tubes are invaded, if they are to be invaded at all. We must not, however, attach undue importance to the gravity of this prognostic, nor regard bronchitic diphtheria as an absolute contraindication to tracheotomy: indeed, on the one hand, it is impossible -from the frequency and rapid development of bronchitic diphtheria-to be certain that an asphyxiated croup patient does not present that compli- cation ; and on the other hand, we know of more than one case of recovery in which false membranes, manifestly moulded in the bronchial tubes, were ejected through the eanula."* Let me now, gentlemen, say a word on the general symptoms and com- plications of the disease. At first, as I have already said, there is febrile excitement. There is also engorgement of the glands, more considerable than in some other kinds of sore throat, but less than in the sore throat of scar- latina, or in malignant diphtheritic sore throat. The fever continues for one or two days, and then ceases, whilst the malady progresses. The pain in the throat is so insignificant that children of four or five years of age who are able to express what they feel, make no complaint of it. This almost complete absence of constitutional symptoms ancl pain in the throat allows the malady so insidiously to make way, that the physician is not called in till it has reached the larynx, that is to say, not till croup has declared itself. By this time, the pseudo-membranous formations which at first occupied the pharynx have had time to become detached, and there may then be hardly any, or not even a shred of them remaining on the tonsils, or on any part of the mucous membrane of the palate. This fact is im- portant : it quite explains the cases in which pseudo-membranous laryn- gitis was supposed to have been developed all at once, and not to have been propagated downwards from the pharynx. We have now, gentlemen, come to the point at which it is necessary to speak of sudden croup: the subject is one which has a good claim on us to stop to consider it. You will hear it said by men, recognized as possessing experience, that they have often seen death from croup in children in whom the pharynx had not been implicated. Prior to Bretonneau reading his first work on diphtheria to the Academy in 1818, before the publication of his treatise in 1826, the occurrence of sudden croup was generally believed : the belief was that membranous croup begun in the larynx. Bretonneau, * Peter (Michel): Des Lesions Bronchiques et Pulmonaires; et particuliere- nient de la Bronchite Pseudo-membraneuse dans le Croup. [Gazette Hebdomadaire, 1863.] 348 DIPHTHERIA. however, maintained and demonstrated that almost always-at least 19 times in 20-the pharynx is the starting-point of the malady. His friend Guer- sant, for many years physician to the Children's Hospital, after having maintained the first opinion, took the same view of the matter as Breton- neau as soon as his attention was awakened to the question. Since that time, every one, at Paris or elsewhere, who has taken the trouble to examine the subject has come to the same conclusion. I have seen perhaps more of croup than the busiest physicians of the capital, from the circumstance of my having been for eighteen years intrusted with the department for sick children in the hospitals, also because, from my having introduced trache- otomy into the treatment of laryngeal diphtheria, I have frequently had the honor of being consulted as to the advisability of that operation; and I declare to you that the proposition of my venerated master is the truth, that in most cases croup begins in the pharynx. But I do not deny that there is such a thing as a sudden attack of croup [le croup d'emblee]. Not only do I believe that the pellicular disease may strike its first blow at the larynx, but I even admit that it may make its first attack upon the bronchial tubes. Examples of this have been men- tioned by Guersant and many others. Dr. Yvaren, in his report on the epidemic of diphtheria which prevailed at Avignon in 1858, states that its special character was the sudden manner in which the larynx and bronchial tubes were attacked. I have already mentioned two cases to you in which the disease appeared simultaneously in the bronchial tubes and trachea, as well as in parts accessible to sight. Why should it be looked on as sur- prising that diphtheria should all at once localize itself in the mucous mem- brane of the larynx, in the same way that it localizes itself in the mucous membrane of the nose, mouth, or vagina? I do not deny, then, that croup may begin in the larynx, but I maintain that its doing so is a rare and exceptional occurrence. The former belief in the greater prevalence of this occurrence arose from the insufficient manner in which patients were examined. The throat was not explored with necessary care; and, again, as the medical man was called in late, there had been time for the pharyngeal false membranes to disappear: the late arrival of the physician arising, as I have already said, from the mildness of the general and local precursory symptoms. When you are sent for to a child who you are told has been ill from croup for only two days, get the relations to recall the preceding circumstances, and you will learn that the child had been suffering for a longer period: you will learn that for five or six days he had been eating less, had been com- plaining of a little difficulty in swallowing, and had been refusing to take any kind of food which was at all hard, such as the crust of bread, and you will learn also that there had been observed a little swelling of the neck: these are symptoms of sore throat, and of the prior existence of false mem- branes which you have come too late to see. To return to the general symptoms: In practice, when you have to do with the diseases of childhood, let me counsel you to be on your guard if there are symptoms present which, though slight in appearance, may in reality be the commencement of a terrible malady. When you see a child which has been suffering for some days from feelings of general discomfort, and an insignificant amount of fever, but is unable to tell you whence its sufferings proceed, at once examine the state of the throat, depress the tongue in such a way as to enable you to see to the bottom of the pharynx, and in many cases you will find that the discomfort has been the announce- ment of diphtheria, and that there is a deposit of false membrane on the tonsils and veil of the palate. DIPHTHERITIC SORE THROAT AND CROUP. 349 In the adult matters pursue a similar course. The general discomfort and the febrile excitement are so slight as to be hardly recognizable, and there is almost an absence of sore throat: you will sometimes meet with patients having the pharynx coated with false membrane, and who never- theless make but very slight complaint of difficulty of swallowing. Here, however, the danger is greater than in the child. As the adult has the laryngeal orifice proportionally larger than the child, and the calibre of the trachea also proportionally greater, the air finds sufficient passage even when the walls of these conduits begin to be covered with false membrane; and by the time that the symptoms of croup declare themselves, the diph- theria has had time seriously to compromise the ramifications of the bron- chial tubes. It is long since these phenomena made an impression on my mind, for I had a good opportunity of examining them in the epidemic of Sologne, which, in 1828, I was sent to study with Dr. Ramon. Allow me to bring under your notice some of the cases which then came under my personal observation. Upon a certain day-a day too memorable for me ever to forget-I was dining with M. de Bethune, whose castle is situated a short distance from Selles, in the department of Cher, when a peasant came for me in urgent haste, declaring that his wife was in a state of suffocation. I immediately went to the patient. I found a woman of 28 years of age dressed in holi- day attire : it was Whit-Sunday. She had attended mass in the morning at a distance of a quarter of a league from her home where she then was : she walked home, dined as usual, and was preparing to go to vespers, when she was suddenly seized with a fit of suffocation, so violent, that her hus- band was afraid that before I arrived she would be dead. When I saw her, the unfortunate woman was in reality dying. Upon at once examin- ing the throat, I discovered that the pharynx was covered with thick false membrane. The nature of the disease was thus demonstrated ; and as the poor woman was in the last extremity, nothing but tracheotomy could pre- vent immediate death. Without any delay, I proceeded to perform the operation : 1 was alone, with the patient's husband as my only assistant; and a convex-bladed penknife, which I fortunately had in my pocket, was my only instrument: having no tracheal canula, I was obliged to hammer a rough sort of one out of a ball of lead. Unhappily the false membrane had penetrated to the minute bronchial ramifications. Next day the pa- tient died. The suddenness of the disaster which occurred in this case gives you an idea of the slightness of the constitutional symptoms by which it had been preceded. The case corroborates my remark to the effect, that in pharyn- geal diphtheria-a disease which when it remains confined to the pharynx is a not very serious local disease-there is generally very little constitu- tional disturbance during the first days of the malady. In a village in the department of the Indre, where the disease was epi- demic, the rural watchman, a man aged 71, was still going about his ordi- nary occupations when I saw him under an attack of membranous sore throat which carried him off next day after frightful suffocative fits. In the same commune, there was pointed out to me a family, several of the members of which had sunk under the disease. I was called to a little girl who was attacked by it. When I arrived at hei' residence she was absent, and had to be sought for in the fields, where she was taking charge of the turkeys. I waited an hour for her : when she came in, she was pant- ing and could hardly breathe. In the evening she died ofcroup. Although this poor child had made no change in her usual mode of life, she had 350 DIPHTHERIA. nevertheless been ill for eight days, though certainly without any marked general symptoms of illness. Like the woman who died in her holiday attire, and the rural watchman who was going about his usual occupa- tions till the day before his death, she had continued to eat, drink, and go out as usual. Do not forget these cases, gentlemen: do not forget that diphtheria very often sets in mildly. If there be any fever during the first twenty-four hours or first two days, it soon ceases, or becomes insignificant. The exist- ence of the malady is hardly announced by a slight difficulty in swallow- ing. The difficulty of breathing comes later : but by the time it has come, the disease has reached the larynx, and will ere long, a little sooner or a little later, suffocate the patient. In so terrible a disease, the prognosis is necessarily unfavorable in the last degree. Left to itself, it is almost inevitably fatal. Here are two examples of recovery ! During the same Sologne epidemic of which I have been speaking, the prefect of the department of Loir-et-Cher informed me that a malignant sore throat was desolating the neighboring communes of Ferte-Beauharnais. I proceeded thither, and at two farms in the commune of Tremblevif (the farms of Roi David and Grand-Pied-Blain), I saw a spectacle as heart- rending as it is possible to witness. At the one farm I only found remain- ing the head of a family and a servant-girl of sixteen years of age. The man was sitting in the chimney-corner, and did not rise even to receive me. His age was 27. He informed me that he and the maid-servant were the sole survivors of eighteen residents in his house and on his farm. The maid also had been ill: but had been cured by the priest of Tremblevif, who had eight or ten times touched her throat with the spirit of salt (hy- drochloric acid). As for himself, he knew, he said, the fate in store for him. " To-morrow, or next day," said he, " I shall die as my children, my wife, my father, and my mother have died." Firmly convinced that such was to be his fate, he would take no measures to avert it. I, however, examined his throat: the tonsils were completely covered with pseudo-membranous exudation : the state of the respiration and voice showed me that the larynx was not yet invaded. I endeavored, to inspire him with hope, and appealing to the recovery of his servant, I said that all was not lost, and that if he consented to be treated in the same manner that she had been treated, he too might be cured. He yielded to my persuasion : and-God helping-my treatment had the hoped-for result. This man was saved. Such, gentlemen, is the appalling mortality which diphtheria brings in its train. Of eighteen individuals, two only escaped death, and these two owed their preservation to energetic treatment. Three years previously, in another department, epidemic diphtheria made such ravages in one of the villages in the environs of Chapelle-Veronge, near Ferte-Gaucher, that of sixty children, nearly all males, sixty died! This fact is stated by Dr. Ferrand.* When I arrived in Sologne, I found the medical men discouraged to such a degree that some of them were unwilling to visit any more patients suffer- ing from malignant sore throat; and the clergy assured me that all who took the disease inevitably died of it. At Marcilly, in Villette, of 650 in- habitants, 66 persons-more than a tenth of the entire population-died of white sore throat, as the parish priest had designated the disease. At a later period, it is true, some recoveries took place, after the adoption of an em- pirical treatment recommended by a woman of the place. It consisted in * Ferrand: Thfese Inaugurate sur 1'Angine Membra neuse-. Paris, 1827. DIPHTHERITIC SORE THROAT AND CROUP. 351 the employment of a mixture of vinegar and alum, such as is used in the country in the treatment of the chancrous mouth and throat of sheep and pigs- Pharyngeal diphtheria, then, is almost always mortal, when its progress is not arrested in time by treatment. There are forms of the malady which nearly always prove fatal whatever treatment is adopted; but the form now under consideration is for the most part curable, when recourse is had to the therapeutic means of which I am going to speak. Apart from paralytic affections, consecutive complications of diphtheria, to which I propose specially to devote a lecture, there are other complica- tions which increase the danger of the case, and blast the hopes of the phy- sician, at the very moment of his counting on a cure from his having succeeded in arresting the progress of the disease by energetic treatment. I refer to enteritis which is common in children ; to pneumonia, to which Ghisi has called attention ; and to interlobular emphysema of the lungs pro- duced by the rupture of vesicles in coughing. The child to whom I have already several times referred, gave us an example of the peripneumonic complication, which we have often met with in other circumstances. Latterly, at the autopsy of another child, we found pulmonary emphysema. The little patient was admitted to the hospital when in the last stage of croup. He seemed dying when the interne on duty performed tracheotomy. At the visit next morning, fifteen hours after the operation, the child had still considerable oppression. We hastened to clear out the internal canula which had become stopped up. The dyspnoea, however, still continued; and we heard during expiration a peculiar sound caused by the passage of air through the instrument, a sound which I have called serratic-stridor serrations-from the resemblance it bears to the noise caused by a saw- serra-cutting stone. This sound is a very valuable sign in forming a prognosis: when I hear it in children in whom tracheotomy has been per- formed, I consider death as inevitable. And so it was in the case of our little patient: he died during the day. On examining the body after death, we saw the larynx and trachea coated with false membrane, which also extended into the bronchi and their very remote ramifications: several lobules of lung were separated by large bullae of cellular tissue distended with air, which having broken up the vesicles had thus caused interlobular emphysema. Bretonneau observed this lesion in two cases which are reported in his treatise on diphtheria: one of the subjects was a soldier of the legion of La Vendee, and the other a young child. The case of the latter occurred during an epidemic in La Ferriere: the emphysema was the result of the violence of the inspiratory efforts, just as in hooping-cough, it is the result of the violence and frequency of the paroxysms. In children upon whom the operation of tracheotomy has been performed, you will sometimes see this emphysema in so formidable a degree as to have reached the cellular tissue of the neck, shoulders, and chest: but it is not the consequence of the operation, as some might imagine, for it existed prior to the operation. Dr. Peter has always met with pulmonary emphysema in the autopsies which he has made of patients who have died of croup. In the majority of his cases, the emphysema was not vesicular: in the cases in which the suffo- cative attacks had been very violent, interlobular emphysema was found. Finally, Drs. Barthez and Rilliet, and also Dr. Henri Roger, have described the occurrence of general emphysema proceeding from the successive inva- sion of the mediastinal and subcutaneous cellular tissue. In a large majority of cases, the emphysema occupies the upper third and edges of both lungs; 352 MALIGNANT DIPHTHERIA. and Dr. Peter says that some observers have failed to see the emphysema, because in place of there being an anaemic and pale condition of the tissue, as is usual in this lesion, there is sometimes congestion and redness of the emphysematous parenchyma.* Malignant Diphtheria. A much more Terrible Form of the Disease.- The Local Affection is as Noth- ing compared to the Constitutional Symptoms.-It Kills, not like Croup by Asphyxiating the Patients by Suffocative Paroxysms, but it Kills by General Poisoning after the manner of Septic Diseases.- Glandular En- gorgement considerable.-Erysipelatous Redness.-Membranous Coryza and Nasal Diphtheria.-Diphtheritic Ophthalmia.-Epistaxis.-Hemor- rhages of every kind.-Anaemia. Gentlemen : In my last lecture I spoke of that form of diphtheria which may be called normal, of that form of disease which, beginning in the pharynx, extends to the larynx, trachea, and bronchial tubes, so constitut- ing croup, which proves fatal by causing asphyxia. That I told you is the most common form: it is the form which it takes when sporadic, and also that which it exclusively assumes in some epidemics: it is even the most common form when malignant diphtheria, of which I am now going to speak, prevails. For instance, in a family in which four, five, or six indi- viduals are attacked, croup will be the general rule, and the malignant form, which carries off persons by general poisoning, will be the exception. During recent years we have had several cases of the malignant form, and among others that of a little girl, in whom you have had an opportu- nity of following the progress of the malady step by step to its fatal issue. The patient was a girl, aged 12, who had on the evening of the preceding day been admitted into the Hotel-Dieu, under the care of my colleague Dr. Jobert (of Lamballe), who sent her to me. Only three or four days had elapsed since she had been seized with sore throat of so slight a character, and accompanied by so little fever, that neither did she make any complaint on the subject, nor were her relations in any anxiety about her state. The malady, however, having increased in severity, and the glands of the neck having become obviously swollen, she was taken to the hospital, and placed, in the first instance, in the surgical department; but, when the nature of the disease was perceived, she was transferred to our St. Bernard's Ward. When examining the mouth, at my first visit, I was struck with the hor- ribly gangrenous fetor of the breath. The veil of the palate was thrust very much forward and to the right, exactly as in inflammatory sore throat when only one side is affected ; but I saw on the veil of the palate a whitish membranous exudation, the extent of which was sharply defined, and which was attached at its upper part in festoon form, near the palatine arch. This diphtheritic membrane, which reached to the pillar of the veil of the palate, became merged in a sort of grayish putrilaginous magma occupying the throat, exuding a grayish sanious fluid of the most disgusting odor. Upon the uvula, pushed completely to the left by swelling of the affected parts, I saw on the right a covering of whitish deposit, while the left side, as well as the corresponding tonsil, were free : on the posterior part of the pharynx we perceived one or two spots of a yellowish-white color. The nostrils were * Peter (Michel): Des Lesions Bronchiques et Pulmonaires dans le Croup. Paris. 1863. MALIGNANT DIPHTHERIA. 353 in a perfectly healthy state. The swelling of the lymphatic glands at the angle of the jaw, and of the submaxillary glands, was considerable on the right side, and there was a great deal of pain in the swollen parts: on the left side nothing noteworthy was observed. I at once came to the conclusion that I had to do with a case of malig- nant pharyngeal diphtheria, one of the most terrible of diseases, a disease which never spares when the physician has failed to employ energetic treat- ment, and is even then implacable in a very great number of cases. My prognosis, therefore, was unfavorable. Although the nose was not yet impli- cated-in which case I should have looked on a fatal issue as inevitable-the great engorgement of the cervical and submaxillary glands seemed of very evil augury. I immediately instituted the only treatment which could afford a chance of success. I vigorously cauterized the affected parts with a solution of nitrate of silver, composed of one part of the nitrate to five times its weight of water, and then insufflated powdered alum by means of a tube. That evening and next morning the cauterizations were repeated, a saturated solution of sulphate of copper being used in place of the nitrate of silver. Six or eight times during the day, in the interval between the cauterizations, powdered alum and tannin were alternately insufflated. I also used all possible means for securing the regular administration of nutriment to the child, so as to make her take, willingly or by force, soup and chocolate, as well as small cups of coffee, as a stimulant and tonic. I at the same time prescribed cinchona in different forms. When I return to the subject of treatment I shall tell you how much importance I attach to the regular administration of nourishment, and why I do so. When the patient had been four days in our wards, her situation was far from ameliorated. The glandular engorgement which had caused me from the first to form an unfavorable prognosis had increased, and involved the cellular tissue of the cervical and submaxillary regions. Moreover, a symp- tom still more alarming had supervened-an erysipelatous redness of the skin, as if there was a deepseated abscess. This erysipelatous redness, a phenomenon to which Borsieri called attention, is met with, as a general rule, only in the very worst form of diphtheria. I shall have to revert to this subject. From the third day we observed that the nostrils were involved. We had noticed, on the evening of the second day, that their lowqr parts were red : this redness increased, and next morning there was a profuse discharge from the surface of the pituitary membrane, a pseudo-membranous secretion with which a little blood was mingled. The malady had extended to the nasal fossae. This is a most unpropitious occurrence, as I shall have to tell you when I come to speak of the course and prognosis of this form of diphtheria; the cases in which it happens almost invariably prove fatal, if not in the acute, in a later stage of the disease. Nevertheless, in the case now before us, the cauterizations were performed night and morning with rigorous exactitude: also, several times in the twenty-four hours, the insufflations with alum and tannin were repeated. The child was fed in accordance with my prescription. About the fourth day, that is, about the seventh day of the malady, the appearance of the throat was satisfactory. The mucous membrane had become almost quite free from the exudation with which it had been covered: the uvula, too, was quite free : and so likewise, very nearly, were the tonsils and lower part of the pharynx. But during the daytime of the third day there were very profuse attacks of epistaxis, which increased the already formed unfavorable prognosis, founded on the glandular engorgement and vol. i.-23 354 MALIGNANT DIPHTHERIA. nasal diphtheria. The child was very pale, and in an exceedingly prostrate state. The first bleeding at the nose occurred immediately after the use of an injection of sulphate of copper, but the injections were nevertheless con- tinued. After each injection there was a considerable mucous discharge from the nostrils; and, on two such occasions, unquestionable pseudo-mem- branous deposit was thrown off, and this in one instance retained the shape of the turbinated bone on which it had been moulded. The formidable symptoms, although the pharyngeal affection was cured, and although I had no reason to dread an extension of the disease to the larynx (respiration being quite normal), led me to foresee a fatal termina- tion : I stated to you that the child would by degrees fall into a state of prostration from which nothing could restore her, that very soon we should see her refuse every kind of food and drink, and that at last she would fall into a condition of syncope and expire. The event only too completely justified my prediction. The little patient grew cold, like a cholera patient: she had a tendency to lipothymia: her pulse was exceedingly weak and slow, but her breathing was free : we tried in vain to get her to swallow something, and to overcome her utter loathing of food. Although there was perceptible diminution of the glandular en- largement ; although the state of the nose was better, inasmuch as there was no longer any secretion of the fetid ichorous discharge; although the erysipelatous redness had disappeared ; although, looking only to the local manifestations, amendment had taken place, that amendment was deceitful, and the child died, poisoned by the diphtheritic poison. In the act of re- fusing to drink, and in turning away from the nursing sister, she fainted, and died without coming out of the faint. This manner of dying is frequent in malignant diphtheria. At the autopsy, we found no trace of pseudo-membranous deposit on the mucous membrane of the pharynx. Under the influence of the topical treatment, complete detersion had taken place, the pillars of the veil of the palate, which had been covered with a putrilaginous detritus resembling gangrene, being perfectly .free from morbid matter: the tonsil was again occupying its usual place, and presented neither gangrenous nor other lesion. This case corroborates a statement I made in my last lecture, to the effect that diphtheria frequently simulates gangrene. The case which I have now related is a case of slow malignant diph- theria : you have seen the swift form in another child, which died about three weeks ago, in the same ward. I shall lay before you accounts of other similar cases. One of my much-lamented hospital colleagues, whose name is known to all of you, and whose works many of you possess, Valleix, was in attendance upon a little girl suffering from membranous sore throat. She recovered from this affection, which was not of a severe character, under energetic treatment adopted by my unfortunate colleague. One day, when examin- ing the throat, he received into his mouth a small quantity of saliva spurted out, in coughing, by the patient: he got the disease. Next day, on one of his tonsils, there was a small pellicular deposit: he had slight fever; and some hours later, both tonsils and the uvula were covered with false mem- brane. Soon afterwards, there was a profuse discharge of serous secretion from the nose: the cervical glands and cellular tissue of the neck and inframaxillary region were a good deal swollen: delirium supervened, and in forty-eight hours Valleix died, without having had any laryngeal symptoms. Very recently, one of my provincial colleagues had a case of diphtheria and croup, in which he was obliged to resort to tracheotomy. During the MALIGNANT DIPHTHERIA. 355 operation, a fear of suffocation arose from/blood getting into the trachea, whereupon, in dismay, my imprudent colleague applied his mouth to the wound in the neck, to suck out the blood from the air-passage: he inocu- lated himself with the disease. Like Valleix, he died in forty-eight hours of malignant sore throat, the symptoms, including the delirium, having been similar. To these lamentable histories, I have yet to add others equally sad. Under very similar circumstances, my friend and colleague, Dr. Blache, had the sorrow to lose his son, one of the most distinguished of our hospital internes, a youth of great promise, in whom the charms of intellect were united with the most solid information. Henri Blache was put, by his uncle, Dr. Paul Guersant, in charge of a child suffering from croup, on whom tracheotomy had been performed. He passed three nights with the child. At the end of the third night, he felt slight pain in the neck, and went home to mention it to his father. Dr. Henri Roger, Dr. Legroux, and I were immediately sent for: we found the unfortunate young man in a very feverish state, and his tonsils covered with false membrane. Within a few hours, the swelling in the neck became enormous, an incessant dis- charge from the nose was established : delirium set in at the end of the first day: and after an illness of seventy hours, our patient died without having had the slightest affection of the larynx. Thus, gentlemen, you see that a special form of diphtheria may be con- tracted by contact with an individual suffering from the ordinary form of diphtheria, just as confluent small-pox may be taken by contact with one who has the distinct form of the disease. In the rapidly fatal malignant form, there seems to be a simultaneous poisoning of the whole system : when the characteristic pellicle begins to appear on the tonsils and in the nasal fossse, the whole economy is already profoundly altered. Fortu- nately, the rapidly fatal is the most unusual form of the disease, though in some epidemics it is too common. From 1822 to 1844, I had not a single case of it, whereas, within the last few years, I have jnet with more than twenty examples in Paris. In two families, to which I was called to cases of ordinary diphtheritic sore throat, I saw several patients carried off' by the malignant, implacable form of the malady. Four years ago, in one of the most illustrious houses of France, five per- sons were attacked by diphtheria: two of the five had the disease in its ordinary form, while the other three-a mother and her two children- were carried off by the malignant, and rapidly fatal form. You will find histories of a considerable number of cases of this description in the reports of the epidemics of malignant sore throat which have scourged France in recent years; and particularly in Dr. Perrochaud's account of the epidemic which ravaged Boulogne-sur-mer from January, 1855, to March, 1857.* Diphtheria, like other epidemic diseases, has at one period a particular prevailing mood, and at another period is in a quite different humor: also, after having ceased to exhibit certain characters, it again assumes them, and thus undergoes diverse transformationsand reproductions of type. I ought to remark, gentlemen, that for some years past, we have been traversing an epidemic period in which malignant diphtheria has been much more frequent than it had been previously. In point of fact, the dis- ease which we have to deal with at present is unquestionably very different from that of which Bretonneau has given us the graphic picture, and recalls to our minds the descriptions of the malady left to us by the physicians of the seventeenth century. * Perrochaud : Memoires del'Academie de Medecine, t. xxii, p. 91. 356 MALIGNANT DIPHTHERIA. Let us now study the slow form of malignant diphtheria, which you will have to treat more frequently than the swiftly fatal form. Though it is frightfully serious-more serious than typhus, cholera, or yellow fever-you may hope to save some patients from its grasp; but as for the form of the disease which snatched from us Valleix and Henri Blache, it pitilessly kills. An example of the slow form of diphtheria is afforded by the case of the young girl whose history I have recapitulated to you. Pellicular deposits appear on one of the tonsils: their appearance is often in no respect different from that presented by the false membrane in ordi- nary diphtheritic pharyngeal sore throat, but they sometimes have a special aspect, being of a tawny yellow color, resting on livid tissues, which are frequently cedematous. The patients complain of pain and dryness of the throat, and difficulty of swallowing: the latter symptom is sometimes com- plained of long before there is any plastic exudation, redness, or other visible change in any part of the pharynx. There is a good deal of fever: though there is not always more fever than in the simple form of the disease. But in the malignant form, there is one symptom which is never absent-a symptom redolent of malignity, to adopt the expression of Mercatus-pestiferi morbi naturmn redolens:-that symp- tom is glandular engorgement. The engorgement is considerable, and ex- tends to the cellular tissue surrounding the lymphatic glands. This sign, from the first of frightfully important prognostic value, leads one to fear that the case is of the malignant form, and will resist all treatment. The skin covering the swollen parts frequently assumes an erysipelatous redness, such as was observed in our little patient; this also is a symptom which unfavorably influences the prognosis. This redness suggests the idea of deepseated inflammation. It is a symptom which did not escape the notice of the physicians of past times. To substantiate this statement, let me quote a sentence from Borsieri's chapter on gangrenous malignant sore throat: "Nee rarum est in hujus modi morbo, prcesertim cum epidemice dif- funditur circa collum, pectus et brachia erumpere ruborem quandam erysipela- todem, scepc cum papulis morbillosis conjunctum aut exanthemata miliaria, papulasve rubras in summam cutem alicubi prodiri, quin imo parotides ipsas glandalasve maxillares jugularesve tumefieri ac dolere." You observe that in this passage, in addition to the glandular swelling and erysipelatous red- ness which I spoke of, mention is made of miliary and rubeolous eruptions, which perhaps bear some analogy to the scarlatiniform, erythematous, net- tley, and pemphigoid eruptions, to which attention has been called by my colleague, Dr. Germain See, and regarding which there was a discussion in the Hospital Medical Society. I now return to the subject of glandular engorgement. It shows itself particularly at the angle of, and below, the maxilla, attacking first the side corresponding to that of the pharynx first affected, then attacking the other side, when the other side of the pharynx has become implicated. The diph- theritic exudation manifests itself more rapidly than in the common form of pseudo-membranous sore throat: it generally covers a part of the veil of the palate. You can recall, as it is of very recent occurrence, the case of the little girl who died of malignant diphtheria, and whose autopsy we made. She specially complained of great pain in the ear, particularly when she coughed. Pharyngeal diphtheria very often extends, by the Eustachian tube, into the auditory passage, and likewise at the same time, to the nose. After twenty-four, thirty-six, or forty-eight hours, the nasal fossae are in- vaded. The existence of membranous deposit is a fact of momentous im- portance, and one to which I called your attention in the case of our little patient of St. Bernard's Ward. Bear in mind the circumstances : for when MALIGNANT DIPHTHERIA. 357 this deposit makes its appearance, even in that form of the disease which sets in mildly, you will rarely see the patients recover, whether they be adults or children. There is, I repeat, no occurrence so alarming as an extension of the disease to the olfactory mucous membrane. Of twenty persons attacked with nasal diphtheria, nineteen die: whereas, in twenty attacked with croup, some may be saved by tracheotomy, as I hope after- wards to show you. You have still, I doubt not, in your mind's eye, the autopsy of a child who was in our wards for four or five days. He took diphtheria when in another hospital. When I saw him, he was breathing noisily, and with difficulty: a thin serosity, devoid of fetid odor, was running incessantly from his nostrils. There was high fever. My first general glance at this patient was enough to inform me of the serious character of the case, and to cause me to tell you that it was diphtheria which would terminate in death. The child, however, had still a fresh and vigorous appearance: but I saw the nasal diphtheria, and my experience had taught me its alarming import. On proceeding to examine the throat, I detected pellicular de- posit on the uvula and both tonsils. A concentrated solution of sulphate of copper was applied to the mucous membrane of the throat and nose, and insufflations with tannin and alum were employed ; notwithstanding this treatment, the child died. In this case, there was not the slightest implica- tion of the larynx. On examining the body after death, we found a thick pseudo-membranous coating on the tonsils: the aryteno-epiglottidean liga- ments presented traces of inflammation and recent plastic exudation, but no false membrane. No morbid change was observed in the larynx and trachea. The child, then, did not die of croup, but of malignant diphtheria ; it was, moreover, the presence of the characteristic exudations in the nasal fossae which caused me to form the unfavorable prognosis so speedily realized by the fatal termination of the case. In what way does nasal diphtheria declare itself? You have seen its mode of beginning in the little girl whose ease has been the subject of this lecture. First of all a redness appears at the orifice of the nostrils, analo- gous to the redness seen in persons suffering from coryza; there is an in- crease in the secretion from the pituitary mucous membrane, the patient blows his nose a little more frequently than usual, the mucus secreted is mixed with a minute quantity of blood, and there are generally at the same time attacks of epistaxis. Coryza, even slight coryza, supervening in diph- theria, is a serious occurrence, for it shows that the specific inflammation has reached the nasal fossae. Within a space of from twenty-four to forty- eight hours, no room for doubt will remain: there will then be a profuse flow of a sanious ichor from the nostrils and into the back part of the throat. On examining the nose, by opening the nostrils with the fingers or by means of a speculum auris, the mucous membrane is seen to be coated with false membrane which can be traced even over the turbinated bones. Our little patient, you will remember, ejected false membrane retaining the form moulded on one of these bones. There is also observable at the same time lachrymation, an almost never- failing symptom, lachrymation resembling that of persons suffering from lachrymal tumors or obliteration of the nasal duct; it proceeds from a sim- ilar cause, for the nasal duct and lachrymal passages are obstructed by tumefaction of their internal mucous lining. In some cases, the diphtheritic inflammation, and even the false membranes, extend from the nose to the eyes. Indeed, on turning over the eyelids, it is not unusual to find, par- ticularly on the lower eyelid, the conjunctiva inflamed and covered with 358 MALIGNANT DIPHTHERIA. pseudo-membranous secretion, the specific inflammation having been propa- gated to it, through the nasal passages, in succession from the pharynx and nasal fossae. This lesion of the palpebral conjunctiva is so common that we every year meet with examples at the Children's Hospital, particularly in the malignant form of the disease now under consideration. The symptoms of nasal diphtheria and of ophthalmic diphtheria are appar- ently so much less alarming than those of croup, that unless the physician has had sad experience of their ominous character, he will not despair of recovery when he sees them. If he looks only to general symptoms, to the moderate character of the fever, and the absence of delirium, he will not consider the debility and glandular engorgement as indicative of much danger: he will fancy that when once the nasal and pharyngeal membra- nous exudations have disappeared, there will remain nothing to fear. It must be admitted, however, that notwithstanding their essentially dangerous and almost always fatal character, recoveries do sometimes occur in cases in which nasal pharyngeal false membranes have been present. From among the rare cases of this kind which I have met, I will now recapitulate the particulars of a case which came under your own observation. The patient was a boy aged ten and a half, with an intelligent counte- nance, light hair, and lymphatic temperament. When brought to me by his mother, on 1st September, 1855, I at once detected paralysis of the veil of the palate. I was told that it had existed for three weeks, and was con- secutive to an affection, which from the description given, had evidently been buccal and nasal diphtheria. From the beginning of the attack, the child had complained of pain in the throat, accompanied by a swelling of the glands of the neck, which had not escaped the observation of the family. The onset of the disease was abrupt, or at least the first complaint of the child was made one day on his coming home from school. He then had high fever. The symp- toms continued for forty-eight hours. During that period he ejected by the mouth and nose white skins [peaux blanches], which his mother' com- pared to pieces of flesh. The symptoms now described ceased sponta- neously, no treatment of any kind having been employed. But they re- turned after two days, and presented similar characteristics. Again the child got rid of white skins by expectoration, and on blowing the nose. With good cause the family took alarm, dreading croup, although it was not known that there were any cases of croup in the neighborhood. The patient did not cough, and his only complaint was of considerable pain in deglutition. The malady continued for six days; there was then a rapid convalescence, and a return to former ways. But still the child had symptoms which alarmed the mother, and induced her to come to seek advice from me. The voice was snivelling, and there was an impediment to deglutition, fluids as soon as taken returning by the nose. I had, therefore, to deal with paralysis of the veil of the palate. On examining the throat, I ascertained that this pendulous membrane did not move in the smallest degree during respiration, and did not contract when I tried to excite it to action by touching it with the tip of a feather. The little patient, moreover, com- plained of impaired vision, stating that he had, as it were, a mist before his eyes. The pupils were completely dilated, and did not contract when subjected to strong light after darkness. Finally, it appeared to me that the gait was a little tottering ; but this symptom had no great significance, because it was alleged that from the time he was a year old feebleness had been perceived in the lower limbs. The circumstance which had most struck the family was a change in the character of the child. Till his MALIGNANT DIPHTHERIA. 359 illness, tractable and quiet, he had, after it, become impatient and difficult to manage. In other respects, the general state of health was satisfactory. The urine was pale, and became slightly turbid when treated by heat and nitric acid. I prescribed a tonic and substantial regimen. Unfortunately, I lost sight of this case. Here then is an example of recovery, without the intervention of art, from nasal diphtheria. Such cases, however, I repeat for the third time, are rare, exceedingly rare; they do not invalidate the general rule which I have laid down. Notwithstanding the mildness of the general symptoms, life is in serious jeopardy in persons attacked with malignant diphtheria, when there is so much glandular engorgement, and when the nasal fossse and palpebral con- junctivae present pseudo-membranous exudations. Attacks of epistaxis, as I have already remarked, often precede the formation of false membrane upon the pituitary mucous membrane: the bleedings at the nose constitute the most important notice of the coming plastic exudation, and they continue to occur till it has almost quite covered the inner surface of the nostrils. Our little patient lost nearly 100 grammes [about 3| fl. ounces Brit, apoth. meas.] of blood by epistaxis-a small quantity certainly, but never- theless, as you remarked, some hours after this hemorrhage, her face was exceedingly pale, and her skin generally had become very blanched. Epistaxis has, from the earliest times, been always regarded as one of the most serious symptoms in diphtheria. " Malignant significationem preebet sanguis stillans e naribus," said De Heredia, one of the authors who de- scribed the epidemics of malignant sore throat which committed ravages in Spain at the beginning of the seventeenth century. A little further on he adds: "Periculosissimus censetur sanguinis fiuxus ex naribus aut ore." Malouin, a French physician, who wrote upon the gangrenous sore throats which he observed in Paris in 1746, also recognized epistaxis as a sign of great danger; he states that several children in Picardy, who had this symptom, died within nine days from its occurrence. But, gentlemen, epistaxis is not the only form of hemorrhage which we meet with ; we meet with subcutaneous ecchymosis, bleedings from the lungs, alimentary canal, and bladder, in fact every kind of hemorrhage, such as we encounter in hemorrhagic small-pox, of which I have already spoken to you. Let me quote a remarkable example from Dr. Peter's work on diphtheria. " On August 1st, 1858," says my colleague, "I was called from the Chil- dren's Hospital to visit Marie P-, a child, at No. 29 Rue de Sevres. For twenty-four hours she had been in high fever, and for twelve hours had suffered from severe sore throat. When I saw the patient, I found tonsilar sore throat, and an incipient scarlatinous eruption on the skin. On the fourth day of the malady the fever was increased twofold,-the patient was coughing, and I detected pneumonia of the right lung, an unusual compli- cation of scarlatina. I prescribed some sulphuret of antimony, and ordered a blister to be applied to the chest. "Next day, August 5th, there was a slight patch of false membrane on each tonsil: the fever was intense: the scarlatinous eruption was of a violet color: the general condition of the patient presented all the charac- ters of adynamia. I prescribed a potion containing quinine, and lemonade as a tisane. I ordered that she should have some meat broth. " On the 7th, the blister was ulcerated, and covered with a pseudo-mem- branous exudation. The false membranes on the tonsils had increased in extent and thickness, and had reached the veil of the palate: they were of a grayish color and exhaled a fetid odor. I caused the blistered surface 360 MALIGNANT DIPHTHERIA. to be powdered with a mixture of quinine and camphor, and cauterized the back part of the throat with nitrate of silver. As an ordinary drink, I prescribed lemonade. " On the 8th, running from the nose had begun : and I perceived a rudi- mentary false membrane at the orifice of the left nostril. The scarlatinous eruption was a little less violet, but there was a burning fever. The ulcer- ation of the edges of the blistered surface was extending, and the false membrane which covered it was thicker. So far from there being any resolution of the pneumonia, there was an increase; in the lower half of the right lung were heard a blowing sound and bronchophony. " On the 9th, 10th, and 11th, there was a general increase in the severity of the symptoms. From the arms and thighs, a very few shreds of epidermis peeled off, and the eruption was slightly paler: but the burning fever con- tinued, and a fetid odor was exhaled from nose and mouth. Around the nostrils, there were excoriations. There was an acrid discharge from the nostrils, which produced excoriation of the upper lip; and one could see that the interior of the nasal fossae was coated with false membrane. The whole of the back part of the throat was invaded by the pseudo-mem- branous product: deglutition was very difficult. The nose and throat con- tinued in a fetid state, notwithstanding the frequent use of injections. " On the 12th, I found symptoms of incipient pneumonia on the left side: while on the right, I heard rales which almost amounted to gurgling: there was profuse expectoration of fetid purulent matter. A scarlatiniform eruption had reappeared. The excoriations on the upper lip were covered with diphtheritic exudation. On the neck, I saw two bullae of pemphigus. "By the 13th, the bullae had become excoriated, and were covered with plastic exudation. There were numerous petechiae and scorbutic ecchy- moses on the parts which'had been subjected to pressure: there occurred attacks of bleeding from the nose, and hemorrhage from the vesicated surface. The false membrane at the back part of the throat was infiltrated with blood. "On the 14th, some bloody sputa informed me that there was pulmonary hemorrhage. There were also haematuria and hemorrhage from the bowels, symptoms which I had foreseen, and which, from the previous evening, I had led the family to expect. During the day, also in accordance with my anticipations, the voice became hoarse from the invasion of the larynx with false membrane. In the evening, the voice was broken, and still more decidedly croupy. "On the morning of the 15th August-the 15th day of the disease-the patient died, after having passed a night of great suffering."* I could not, gentlemen, place before you a more complete or a more sadly interesting case than that which I have now detailed. Granting that scarlatina played its part, the child died from a frightfully malignant diph- theria. Scarlatinous sore throat was the starting-point of the diphtheritic inflammation, whence originated the pellicular affection to which death was due. Whether it was from the special character of the diphtheritic disease, or from the individual attacked being already under the dominion of a formidable-and septic malady-in a word, in a condition suitable to the engendering of malignity-the diphtheria assumed its terrible form. The great blanching of the skin, the anaemic appearance to which I directed your attention, could not be exclusively attributed to the loss of blood sus- tained by the patient; forthough such losses maybe relatively insignifi- * Peter (Michel) : Quelques Recherches sur la Diphtherie: rnemoire couronne par la Faculte de Mddecine, 1859. DIVERSITY OF LOCALIZATION IN DIPHTHERIA. 361 cant, or absolutely wanting, there will yet occur decoloration of the skin. In point of fact, decoloration is a constant and invariable phenomenon in the malignant form of diphtheria: it is a sign of the cachectic state into which the individual has fallen. Out of that condition arise a series of symptoms against which we are quite unable to contend. There is a dislike to food, which is quite invincible, both in adults and in children. I have often tried to struggle against it: many times, with children, have I em- ployed every sort of device, threats, and even force, to compel them to take nourishment, but all to no purpose; they resisted every means used, would take neither food nor drink, and at last died from abstinence. The surface becomes cold. There then supervene extreme restlessness, and an anxiety of countenance painful to witness, resembling that which is seen in choleraic patients ; or, there is sometimes a kind of stillness which is even more alarming than the restlessness. At last, unexpectedly, the patient getting up abruptly to satisfy a call of nature or change his position, dies suddenly in a faint. This happened in the case of our little patient. That poor little girl, gentlemen, has afforded you a typical example of the frightful disease, a picture of the leading features of which I have now attempted to sketch. 'Preserve this typical case in your memory ; for, unfortunately, you will too often meet with others like it in the course of your practice. Diversity of Localization in Diphtheria. Palpebral Diphtheria.- Cutaneous, Vulvar, Vaginal, Anal, and Preputial Diphtheria. Gentlemen: I have stated to you that diphtheria manifests itself on the mucous membranes, and also on the skin when denuded of its epidermis. I said that the pharynx was its favorite seat, and that thence it extended to the larynx and trachea. I described to you pseudo-membranous sore throat, that form of the disease which is most common, which produces croup, and thus may come to a fatal termination by inducing asphyxia. I also pointed out that the pellicular affection sometimes all at once takes possession of the larynx, trachea, and bronchial tubes, but that croup occurring in this sudden manner is much more uncommon than was at one time supposed. I called your attention to nasal diphtheria, and to diph- theria of the Eustachian tube. I now propose to make a review of the dif- ferent situations in which we find the manifestations of diphtheria. I have shown you, gentlemen, how the pellicular affection advances from the nasal fossae to the eyelids. I must in a special manner return to this point, that I may read to you a description given by Dr. M. Peter in his remarkable work from which I have already quoted : "At its first appearance," says this young physician, "diphtheria of the conjunctiva, in the three cases which came under my notice, resembled simple catarrhal inflammation of the mucous membrane, there being an injected and dry condition in the beginning, and then lachrymation ; but after a few hours, as the case progressed, it became more like purulent oph- thalmia. The eyelids became swollen, so as to cover up the globe of the eye : the skin was shining, and stretched over the cellular tissue, which was infiltrated with lactescent serosity : a sero-mucous stillicidium was soon replaced by a profuse running, which from its acrid property traced a red- dish painful ridge down from the angle of the nose. " The eyelids were very sensitive to the touch, and on proceeding to 362 DIVERSITY OF LOCALIZATION IN DIPHTHERIA. make an examination, violent cries and energetic resistance were excited. Their (edematous tension and spasm placed obstacles in the way of explora- tion, which it required the greatest possible efforts to overcome. If one succeeded in raising the eyelid, the conjunctiva is seen to be lined with a layer of plastic exudation between one and twro millimetres in thickness : beneath the mucous membrane, there was sometimes seen a bright, bloody- looking redness: the globes of the eyes were bathedin a sero-purulent mucous secretion. " In two of the three cases, I have seen this secretion, the acridity of which was so great that it destroyed the epidermis and excoriated the skin, invade the cornea, infiltrating itself between its laminae, depriving it of transparence, and causing perforation. This, to a certain extent, physical consequence of palpebral diphtheria, caused the resemblance to purulent ophthalmia. "Again, in two of the three cases, along with the affection of the eyelids, there was a pseudo-membranous coryza: the eyelids and the lower half of the nose, from their red and swollen condition, contrasted strongly with the rest of the face, which was of livid paleness, and sometimes had a skeleton- like thinness. In these two cases, there was seen at each side of the mesian line, on the upper lip, and at the angle of the nose, the same inflamed ridge, produced by the same acrid running. " In two of the three cases, there was pseudo-membranous sore throat. In all the three cases, the general symptoms were exceedingly severe. In two cases, there was loss of vision from the implication of the cornea. In two cases, death was the result of the general effect of the disease on the econ- omy. In two cases, the progress of the disease was very rapid, being four days in the one and twelve days in the other : in the latter case, recovery took place. The third case, speaking relatively, was chronic: in it, after twelve days, both cornese were quite destroyed. In none of the cases was there any affection of the air-passages."* Dr. Peter remarks that one might in such cases at first suppose that the disease was purulent ophthalmia, were not the diagnosis elucidated by the concomitance of plastic coryza or pseudo-membranous sore throat: but a careful examination of the eyelids will never leave any doubt as to the real nature of the local affection. The prognosis is unfavorable : it is unfavorable on account of the lesion itself, which may lead to the loss of the eyes: it is unfavorable in respect of the general disease, for in Dr. Peter's three cases, the plastic ophthalmia was the manifestation of a malignant diphtheria. The treatment adopted was cauterization with the nitrate of silver, which was applied to the affected surfaces, after they had been cleared as much as possible from the plastic exudation : the affected parts were likewise well washed with water every hour. Let me quote another case, in which there was a different localization of the diphtheria-a case of vaginal diphtheria. A woman, aged 21, at the full term of her first pregnancy, during which her health hftd been excellent, was seized with labor pains on the night of Friday, 18th', and Saturday, 19th November, 1859. The first stage of labor was slow, the uterine contractions not being strong; and the second stage was still slower: from three to seven o'clock in the evening of Saturday, not the least progress was made. Dr. Campbell, who was in attendance upon the patient, then resolved to deliver by the forceps. The operation, performed while the patient was in a state of complete anaesthesia from * Peter (Michel) : Quelques Eecherches sur La Diphtherie, 1859. DIVERSITY OF LOCALIZATION IN DIPHTHERIA. 363 chloroform, was long and difficult. After twenty minutes of arduous ma- noeuvring, a large and well-formed male infant was extracted. It had slight excoriations on the face and head, the result of bruising with the blades of the forceps. One of the contusions implicated one of the seventh pair of nerves, as was indicated by paralysis of the left side of the face prevent- ing the infant from taking the breast. The mother, however, seemed to rally from the fatigues of labor, and the next day felt herself to be going on well. On the morning of Monday, she was seized with pains in the left groin, shooting into the lumbar region and down the thigh. Drs. Campbell and Blondeau, who saw the patient some hours afterwards, detected incipient peritonitis, characterized by pain, increased by pressure, in the left iliac fossa. There was no swelling of the genital parts. In the evening, the pain was more acute, there was a good deal of fever, heat of skin, and the pulse was above 100. The mind was not affected. There had been neither vomiting nor nausea. The abdomen was smeared with a combination of the extract of belladonna and opium, in the proportion of three of the former to one of the latter; and it was also covered with large poultices of lintseed meal. On the Tuesday, the condition of the patient seemed to be worse: the pain in the left iliac fossa continued, and in the right, there was also pain, though in a less degree. There was a good deal of fever. Ten leeches were applied over the iliac fossa. In the evening, the pain had extended to the whole abdomen. Next day, I was summoned in consultation. When I arrived, at half- past nine in the morning, the peritonitis, which was then general, had reached the peritoneal covering of the diaphragm, as was indicated by the difficulty and pain which accompanied inspiration. The patient was affected with the peritoneal form of puerperal fever, of which there were at that time numerous cases in the wards of the Hotel-Dieu and Hospice de la Maternite. The fever was high: the skin was hot and parched: the pulse was 120. The patient had her mental faculties entire, and retained her cheerfulness. To the inexperienced eye, there was nothing in her situation to cause alarm: we, however, were in very great dismay, because we remembered having seen cases of puerperal women dying of peritonitis, in whom, at the beginning of the attack, no symptoms of any gravity had shown themselves. We prescribed the internal use of the essential oil of turpentine, from which in similar cases we had obtained real service: the external use of the belladonna and opium was continued. Every hour she got some of the essence, care being taken to secure tolerance of the drug by giving along with each dose a drop of laudanum, as soon as diarrhoea supervened. On the evening of Friday-the fifth day of the disease-we perceived a decided amelioration. The abdomen was supple: there was no longer any abdominal pain, and palpation even did not excite it. The uterus was naturally contracted, and there only remained a little pain over the broad ligament on each side, in which situation we discovered considerable swell- ing. The pulse had fallen to 108 from 120, and even from 130, to which it had risen on the previous day. The temperature of the skin was good. We were hoping that we had attained the beginning of convalescence, when other symptoms supervened, which carried off this poor woman in thirty-six hours. I have said that in the first days of the attack, there was no swelling of the external genital organs. On the Wednesday morning, however, this swelling w'as manifest: the swollen parts were painful, but the pain was calmed by the application of poultices of lintseed meal. This affection, sufficiently accounted for by the bruising in the obstetrical manipulations, 364 DIVERSITY OF LOCALIZATION IN DIPHTHERIA. presented nothing visible which was worthy of notice, excepting a slight excoriation of the labia, where a tear had been made by the forceps : this tear was about half a centimetre in length. On the Thursday, however, the sixth day after delivery, on examining the parts, and on using the catheter, it was found that there was a large blackish-gray patch on the left side of the vagina: around this patch, the mucous membrane was of a dull red color, and presented plastic exudation, which I detached with the handle of a spoon. Vaginal diphtheria "was thus only too evidently char- acterized. The part was at once energetically cauterized with a saturated solution of sulphate of copper; and an ointment strongly charged with tannin was then applied to the affected parts. Under the use of these means, which were repeated several times in the twenty-four hours, the progress of the malady seemed to be arrested : at all events, on the Friday evening, when I examined the parts, and detached the sloughs which I had produced, I perceived that the subjacent mucous membrane was of a beau- tiful bright red color, and that no more diphtheritic patches were visible. The peritonitis was proceeding in a fair way to resolution : we believed ourselves to be masters of the diphtheritic affection, the terrible complica- tion which had but a short time before deprived us of every ray of hope: we were in fact thoroughly pleased with the aspect of the case, when (about three hours after my visit) the condition of the patient became very much disturbed. Her pupils wjere dilated : she complained of pain in the throat, and difficulty in deglutition. As there was no fever, and as on attentively examining the pharynx, neither redness nor trace of plastic exudation could be discovered, Dr. Blondeau attributed the symptoms to the action of the belladonna, of which there was still a thick coat on the surface of the abdomen. He carefully washed the skin of the abdomen ; and for some hours afterwards the young woman's state seemed more favor- able. But during the night-about three in the morning-more formida- ble symptoms appeared. The patient awoke from a slumber in a very agitated state, and tormented by disagreeable visions. Her haggard coun- tenance expressed the most intense anxiety ; her pupils were very much dilated : there was considerable dryness and pain of throat: the pulse was 140. Upon again carefully examining the pharynx, there was absolutely nothing noteworthy to be seen. All the symptoms were put down to the account of the belladonna ; and to subdue them, strong coffee was pre- scribed. Next morning, there was anxiety, febrile excitement, a pulse of 130, and only a slight increase in the temperature of the skin. She had passed a sleepless night; but from the beginning of her attack, she had suffered from insomnia. The peculiar expression of the countenance, and the drawn features, proclaimed a great change: the pupils were dilated, and the breathing was labored ; everything indicated excessive disturbance of the system. In the evening, the symptoms of malignity were still more decided. Next morning, we came to the conclusion that this unfortunate young woman was under the influence of malignant diphtheria, and that the uterus was the centre of the mischief. In about six hours, our worst fears, at least as to the nature of the disease, were only too well confirmed, for at midday, we saw, behind the right pillar of the veil of the palate, a characteristic exudation of a tawny yellow7 color of the size of the nail of the little finger. No time was lost in vigorously cauterizing the affected spot, and stripping off its covering of false membrane. Unfortunately, it was trouble lost, as wre found ourselves confronted by that malignant form of diphtheria regarding which I am now7 lecturing-that form of diphtheria in which local manifestations go for little as compared to the general symp- DIVERSITY OF LOCALIZATION IN DIPHTHERIA. 365 toms, and in which topical treatment is of exceedingly little use. At six o'clock, three hours after the appearance of the pharyngeal false mem- brane, the corresponding side of the uvula was implicated : some hours later, the entire veil of the palate was involved, and covered with a livid yellow exudation lying on the mucous membrane, which was cedematous and of a dull red color. The urine was found to contain a considerable quantity of albumen. About two o'clock in the morning, the patient felt that her end was approaching. She spoke to her family with great com- posure, and died quietly, almost without a struggle, at a quarter past eight. On the same day, her infant died of diphtheria. On the Thursday, we had observed in the infant a plastic exudation on the alveolar margin of the upper maxilla. Cauterization with solid sulphate of copper completely modified the affected surface, and no more exudation appeared on it. But behind the left ear, on the excoriated skin, there was plastic exudation : this surface was cauterized, and it cicatrized rapidly. The excoriations produced by the forceps on the hairy scalp became in their turn affected: one of them, now a sore deep and penetrating to the right parietal bone, had a grayish coating, with edges of erysipelatous redness. The facial paralysis prevented the infant from sucking, but it took milk from a glass. It was attacked with vomiting and diarrhoea : the face became pinched, and the body wasted rapidly. On the Sunday morning, convulsions super- vened, and recurred incessantly till death took place at six o'clock in the evening, being ten hours after the mother's decease. These two cases are of such importance as to be laid before you in detail. Possibly, while the diphtheritic poisoning may have imparted to the puer- peral state, both in mother and child, its appalling malignity, it may also, through its terrible influence on the economy, have arrested the peritonitis, which ceased with unlooked for promptitude. It is not an unusual occur- rence for a lying-in woman to be attacked with diphtheria. Sometimes, and possibly it was so in the case of our young woman, the pellicular affec- tion invades the surface of the uterus, becoming developed on the placental wound, as occurred in numerous cases reported by Dr. Behier. Diphtheria of the genital organs is an affection frequently met with, espe- cially in hospitals for children, where diphtheria is exceedingly contagious, and is, so to speak, established in permanence. In little boys, we met with excoriations of the gland and prepuce : in little girls, with excoriations of the vulva and genito-crural fold, so common a sequel of measles : in both sexes, excoriations of the anus constitute the door through which the dis- ease enters-these excoriations becoming covered with plastic exudation. In the medical expedition, which, along with Dr. Ramon, I made in 1828, in the departments of Loiret and Loir-et-Cher,* I visited the com- mune of Chaumont-sur-Tharonne, situated between Romorantin and the Ferte-Beauharnais, where an epidemic of malignant sore throat was very prevalent, and where several persons had already been carried off by it. The daughter of the watchman of Chaumont, servant at a farm-house some distance from the village, feeling the first symptoms of diphtheritic sore throat, ran home in dismay to her father's house in Chaumont, and died there a few days after her arrival. She occupied the same bed with her mother, aged 40, and a young sister. The day after her death, her mother experienced dreadful pains in the vulva and lower part of the abdomen. Her husband examined the affected parts, and it is from him that I obtained * An account of this expedition was published in the " Archives Generates de M6decine, " for July, 1830. 366 DIVERSITY OF LOCALIZATION IN DIPHTHERIA. an account of them. " I looked and saw," said he, to use his own exact words, " what resembled the throats of our children, and which also had a very bad smell: in the inside it was gray and black, and round about it was red." This woman died in five days from the time she began to com- plain, and eight days after the death of her first daughter. Scarcely had a week elapsed ere the second daughter perished of laryngo-tracheal diph- theria. Facts of a similar nature were observed at Mezieres (Loiret). Malig- nant sore throat appeared in the family of the watchman of the castle, where a child six years old had died. Soon afterwards, four daughters of a man named Adam who lived in the court of the castle died of diphtheria. One of them, seven years old, had simultaneously the hands, feet, and vulva invaded by pellicular inflammation similar to that which had possession of the throat: she did not die of suffocation, but sunk into a state of pro- found adynamia which soon terminated in death. This case was commu- nicated to me by Dr. Carriere, physician at Clery, to whom I am also indebted for the following history. A man named Montigny, who had seen, within a month, six of his chil- dren die in succession of malignant sore throat, out of seven attacked, felt the first symptoms of that malady, while at the same time the prepuce became covered with false membrane. Dr. 1'Epine, physician to the prytaneum of La Fleche, saw a similar case during the epidemic which prevailed in that establishment. In his paper he says: " Mary, nursing sister in the infirmary of the school of La Fleche, had from the earliest days of her illness presented very aggravated symp- toms of malignant sore throat. The disease, after having made great progress on the tonsils, appeared at the anus. The anus, very much swol- len, painful, and of a livid red color, was covered with a diphtheritic pellicle, which could only be detached bit by bit, and very slowly. After showing for several days decided symptoms of amendment, she fell into a state of extreme adynamia, having very frequent and protracted fits of syncope. She died on the seventeenth day of the malady." Cutaneous diphtheria is still more common than the other forms of diph- theria which I have just been describing. It most commonly shows itself upon the surfaces to which blisters have been applied, in the folds of the skin met with in too fat children, upon chafed surfaces, upon herpetic vesicles, upon chapped breasts, upon cuts, upon excoriations of the scrotum, upon the slightest solutions of continuity, and, in a word, wherever the skin is denuded of its epidermis, and wherever there is cutaneous irritation aris- ing spontaneously or from an injury. It supervenes in persons who have a diphtheritic affection in some part of the body, as, for example, pseudo- membranous sore throat; or, its appearance may be the first declaration of the disease in individuals who have been in contact with diphtheritic patients. Attention was directed to cutaneous diphtheria by Chomel in 1759; and by Samuel Bard in an epidemic which he observed at New York in 1771. The following is the notice of the affection given by the American phy- sician : " One of the first families," says he, " in which the malady appeared was that of Mr. William Weddle. There were seven children in the house, all of whom fell ill one after the other. The four who were first affected, the youngest of the family, had pharyngeal sore throat, and three of them died. They had no embarrassment of the respiration, but that symptom was re- placed by bad ulcers behind the ears. These ulcerations commenced as distinct red patches, which soon became united. They caused intense itch- DIVERSITY OF LOCALIZATION IN DIPHTHERIA. 367 ing, and profusely exuded an ichor, so acrid as to erode the neighboring parts in such a way, that within a few days the erosion occupied the space behind the ear, and extended down to the neck. All the patients had fever, particularly at night. One suffered from constant tenesmus, a symptom present in several of those who had difficulty in breathing, but in none did it exist to so remarkable a degree as in the case referred to. Several had ulcerations behind the ear similar to those now described ; and some pa- tients seemed to be affected with slight difficulty of breathing. The ul- cerations continued during several weeks, and at various points became covered with a pellicle similar to that on the tonsils; and they also became very painful." My attention was never so much occupied with this subject as during the medical expedition to which I have referred, and regarding which I am now going to speak. Dr. Ramon and I were informed that malignant sore throat had just broken out at Nouan-le-Fuzelier, in the department of Cher-et-Loir, a village on the road from Orleans to Bourges, and that it had already de- stroyed victims there. We went thither; and Dr. Lemenager, a physician residing in the place, had the goodness to go with us to the houses of the patients. Our first visit was to the house of a woman named Josephine Pressior. It was situated at the northern extremity of Nouan ; and up to that time there had been no cases except in the southern district, in a hamlet called Les Rois, a little detached from the village. Josephine in- formed us that her daughter, a girl of 18, had had some intercourse with an infected family in the hamlet of Les Rois, and that soon afterwards she had been attacked by pharyngeal diphtheria. When we saw7 this young woman, she w7as in the eighth day of the malady. Dr. Lemenagar had applied leeches to the neck, had three times touched the back part of the mouth with a solution of nitrate of silver, and had several times insufflated alum. He had likewise, through dread of gangrene, had a camphorated decoction of cinchona injected into the throat, and had prescribed alum and quinine gargles. On the fifth day of the disease, a blister was applied to the nape of the neck: profuse suppuration supervened, the abraded sur- face became covered with false membrane, and likewise an old ulcer on the foot became similarly coated. I found the child's back in the following condition : the blistered surface, which originally was not more than three inches broad, w7as now more than six; it was horribly painful, and was suppurating profusely; it extended over the back, making irregular deviations like the marks called "points" on a backgammon board; and it was surrounded by a large erysipelatous areola, much more apparent below7 than above or at the sides. The part denuded of epidermis seemed to be, and really was depressed, in consequence of the surrounding tumefaction. It was covered with superimposed layers of yellowish-white fibrinous deposit, which was thickest in the centre, and gradually became thinner as it approached the circumference. In the middle, the thickness of the deposit w7as from tw7o to four lines; it bore an exact resemblance to the dry pleuritic concretions found in the cavity of the chest when resolution has begun, and when the serous fluid which was effused has been almost entirely absorbed. On raising some of these con- cretions by means of a very thin leaf of metal, we saw that they adhered strongly to the cutaneous tissue, and that there was a certain amount of difficulty in detaching them. It ought to be mentioned that butter only had been used in dressing the blister. The surrounding erysipelas had a singular aspect. The nearer to the excoriated parts, the more intense was the redness. At numerous points, DIVERSITY OF LOCALIZATION IN DIPHTHERIA. 368 the epidermis was raised up by small collections of lactescent serosity, so that the skin was covered with confluent vesicles in the neighborhood of the wound : as the distance from the healthy skin diminished, so also di- minished the number of the vesicles. Some of the vesicles seemed to be formed by the union of several: there were others which had burst, either when single or united, and in their place there was seen a white mem- branous exudation covering the dermis. These ulcerations became united to others of smaller size, and ultimately they all coalesced with the prin- cipal ulceration : in this way the disease advanced step by step. Let me add the mention of a fact which is remarkable, viz., that the erysipelas rarely spreads in the regions of the head and shoulders, and is indeed sel- dom met with in these situations. Josephine Pressoir, the mother, being in the fields five days before her daughter fell ill, was seized with acute pain in one of the breasts, in con- sequence, as she said, of catching cold. Inflammation of the mammary cellular tissue soon supervened, and an abscess formed. The pus found an exit for itself: at the most elevated part of the tumor, the skin became mortified to the extent of about three lines, and thus the abscess opened spontaneously. I saw the woman the day after this occurrence : the wound was already surrounded with an erysipelatous circle, and the edges of the ulceration were covered with a false membrane which extended over the integuments for a space of from two to three lines. The woman's daughter was at this time in the eighth day of her diphtheria: during all her ill- ness, she had never discontinued to sleep with her mother. At Blettiere, a farm in the commune of Marcilly-en-Villette, department of the Loiret, five persons died of pharyngo-tracheal diphtheria. P. A. Hure, aged ten, slept in the same room and bed with those who were car- ried off by the malady. Very soon, a slight inflammation which he had behind the ears became aggravated, the skin became covered with false membrane, pellicular inflammation extended over the whole back; and he died in a few days, exhausted by horrible pain and excessive suppuration. Dr. Regnaud, physician at Ferte-Saint-Aubin stated that he had seen another patient die at Marcilly in an exactly similar manner from cutaneous diphtheria, which commenced in some ulcerated pustules of porrigo favosa in the hairy scalp, whence it extended to the neck, back, and down even to the loins. He also communicated to me the history of a man of Marcilly, in whom the skin of the scrotum, previously excoriated, was the seat of a diphtheritic affection. At Grand-Pied-Blain, a grange in the commune of Tremblevif, rather less than a quarter of a league southeast from Ferte-Beauharnais, twelve persons were attacked with malignant sore throat, and ten of them died. To the mother of three of the deceased children, a blister had been ap- plied as a measure of precaution-as a means of preventing the disease! But in a few days, a frightful inflammation took possession of the blistered surface and surrounding parts: in a very short time, the unfortunate woman was dead. I was told that the skin of the neck had been attacked by gangrene. Similar events were observed in the family of Bouzy at the hamlet Des Rois, near Nouan-le-Fuzelier. Cases had already occurred in most of the houses in the hamlet; and a little girl died of the malady in a room im- mediately adjoining that of Bouzy. A young man named Cauqui, aged 19, slept in the same room with Bouzy, his wife, and his child. He took malignant sore throat: Bouzy, terrorstruck, applied a blister to both arms of his child "to draw out the bad humors:" almost immediately, the blis- tered surfaces became covered with false membrane, and the surrounding DIVERSITY OF LOCALIZATION IN DIPHTHERIA. 369 skin became inflamed. On the fourth day of the malady, when I first saw this child, the nose was obstructed by pellicular exudation, there was an extremely fetid serous discharge from the nostrils, and the diphtheria was beginning to invade the pharynx. At Saint-Loup, department of Loir-et-Cher, of twenty-one persons at- tacked with diphtheria, nineteen died. An individual named Blaise, deputy of the mayor, and his wife, had just left their two children : they themselves were suffering from malignant sore throat when I was taken to their house by Dr. Macaire of Menneton. The husband was already improving, thanks to the topical treatment which had been adopted ; and his wife, whose larynx had been invaded by false membrane, was beginning to breathe more easily, but a blister had been put on the left arm, which was in a truly frightful state. The blistered surface was remarkably enlarged, had the appearance of being much depressed, was covered with a blackish-gray pellicular exu- dation, and was discharging a very fetid clear serosity. The arm, forearm, and hand were swollen and had a glistening rosy color. It was very diffi- cult to believe that the blistered surface was not the seat of mortification; but on pricking it with a pin, I found that beneath the false membrane, the surface was exceedingly sensitive. I powdered the broken cutaneous sur- face with sublimated calomel. Next morning, the pain and swelling had almost entirely disappeared : the same treatment was continued. Three days from the commencement of the treatment, the wound was quite cleansed, laudable pus was being secreted, and the false membrane had entirely dis- appeared. All that remained was a small slough, which separated in twelve or fifteen days. A boy had just died of tracheal diphtheria at a farm in the department of the Indre. Dr. Bonsargent, called in too late, was unable to afford him efficacious treatment. But he had ordered some leeches to be applied to the abdomen of the mother, who was complaining of pains in that region. The leech-bites were soon inflamed ; and the skin, after becoming erysipela- tous and denuded of epidermis, was speedily covered with false membrane so exceedingly fetid as to simulate gangrene. Frangois Miniere, aged 45, a district roadman of Chaumont-sur-Tharonne, department of Loir-et-Cher, had two children suffering from epidemic sore throat. One died : the other was cured by topical treatment. While mat- ters were thus going on, the father, who had an excoriation at the inside of the metatarso-phalangeal articulation, began to feel acute pain in that sit- uation. The skin soon became erysipelatous and denuded of epithelium : some days later, there was a foul ulcer, with thick uneven edges, surrounded by a considerable amount of swelling: its surface was covered with grayish false membrane, which could be easily stripped off*. The glands of the groin and inside of the leg were a good deal swollen. About six grains of cal- omel were sprinkled over the affected parts. In thirty-six hours, the ulcer had diminished one-quarter in size, the pain was less acute, the swelling had disappeared, and there was no longer visible any false membrane. I dis- continued personally to apply the calomel, leaving some of it for use ; but the patient lost it, and the ulcerated surface which had been so speedily re- duced in size, remained stationary for a long time. A young boy of Marcilly-en-Villette, by name Denis-Lubin Maitre, and likewise his mother, had had for some time diphtheria of the gums, a form of the disease regarding which I shall afterwards have to speak to you. He died of diphtheria, which simultaneously invaded the throat and hairy scalp. This boy had tinea. His brother, aged 13, a cow-herd at Colom- bier, commune of Menestreau, came to Marcilly when his father and sister were ill: soon after his return to Colombier, ulcerations which he had on vol. i.-24 370 DIVERSITY OF LOCALIZATION IN DIPHTHERIA. his head became horribly painful, and discharged a great quantity of fetid serosity. I got these particulars from the boy himself, and from Madame Briolet of Cyran who attended upon him, and who cured him. This patient was the cause of the epidemic breaking out in the place where he resided. I shall recur to this history, when 1 make some remarks on the contagion of diphtheria. At Paulmery, near Selles, a young girl had contracted the disease: she went home to her family at Barres (department of Indre), a farm situated a league from Paulmery, where she very soon died. Her two sisters also died. Their mother, who had attended upon them, took diphtheria, which attacked the neck and the whole of the right side of the face: she did not die, but she had a great deal of suffering and a tedious recovery. At Gra§ay (Indre), an unweaned male infant was seized with diphthe- ritic sore throat, which was prevailing as an epidemic. Up to his death, his mother suckled him : her nipple soon became invaded by the special in- flammation, and covered with false membrane, the extension of which was arrested by appropriate treatment. At the same period, Dr. J. Bourgeois observed at Ferte-Saint-Aubin, in a family of seven persons, an epidemic of diphtheria, which affected the skin in all the seven, and in one little girl the vulva: in a boy who died of croup, the first seat of the disease was the thigh, at a point slightly excori- ated by the friction caused by the edge of a wheelbarrow in which he had been drawn by a brother, who was carried off', seven days before the former, by laryngeal diphtheria. Since these occurrences, gentlemen, similar facts have greatly multiplied, and there are few physicians who have not met with some such cases. You have, yourselves, observed a certain number in the clinical wards. In a female infant of eighteen months, who occupied bed No. 18 of St. Bernard's Ward, I showed you the pellicular affection behind the ears where there had been eczema. You recollect a little boy, four months old, in whom diphtheria declared itself in the front of the neck, upon red spots which had formed between the folds of the skin ; it soon extended to the ears : repeated cauterizations with the perchloride of iron led to recovery. In other cases, the surfaces to which blisters had been applied were attacked : and among the cases of this description was a male child who lay in bed No. 15 of our nursery ward. He had a blister on the arm, which was the cause of his contracting the disease from a woman in our wards who lay close to his cradle, and who had plastic stomatitis. It is hardly four years ago since I was sent for by a physician to see a child with pharyngeal diphtheria. The progress of the disease had become arrested under the influence of very energetic topical treatment; but the attending physician had thought it necessary to apply a blister to the front of the neck. I expressed to my colleague the fears which I entertained re- garding the blistered surface, which I said there was every reason to expect would soon be covered with plastic exudation, which would soon probably invade the front of the chest. I advised recourse to vigorous measures. My anticipations were but too completely realized. The whole of the neck and the front of the chest became involved in diphtheritic disease; and the little patient died, not of croup, but of general diphtheritic poisoning. Very recently, I was asked to visit a girl, ten years old, who, for some days, had had behind the ears, diphtheritic patches,developed probably on an eczematic surface. The eczema had been neglected, from, I regret to say, the singularly mistaken idea of the attending physician, that it ought not to be interfered with, its existence being, in his opinion, rather a favor- able than an unfavorable circumstance. The throat, however, was in turn DIVERSITY OF LOCALIZATION IN DIPHTHERIA. 371 attacked; and when I saw the child, I found both tonsils covered with false membrane, which-as well as the cutaneous deposits-I hastened energeti- cally to cauterize. The little girl recovered. What are the characteristics of cutaneous diphtheria? As soon as it effects a solution of continuity, pain is felt in the part: forthwith, there is a profuse discharge of fetid, colorless serosity; and very soon the surface is covered with plastic exudation, flabby, grayish, and variable in respect of thickness. The edges become swollen, assume a violet-red hue, and appear much raised above the level of the bottom of the sore. The disease, how- ever, does not generally extend, and may remain stationary : sometimes, however, even when only the epidermis has been removed, we see the dermis become at once covered with a white plastic exudation, similar to that ob- served upon surfaces to which blisters have been applied. Not unfrequently, erysipelas appears around the excoriated part. The epidermis of the ery- sipelatous surface is raised up at numerous points by little collections of lactescent serosity, in such a manner that the skin in the neighborhood of the sore is covered with confluent vesicles: the vesicles gradually decrease in number with the increase in the distance between the sound skin and the sores. Some of the vesicles seem to have been formed by the union of several: and others, simple or aggregate, burst, when in their place is seen the dermis covered with a white plastic exudation : these excoriations unite with smaller ones, and thus form a junction with the principal: it is in this way that the disease accomplishes its progressive invasion. Thus it is that diphtheria, commencing in a slight excoriation of the hairy scalp, or on the skin behind the ear, may invade the skin down to the loins, as I have seen in several cases. The pellicular deposit, at first thin, becomes gradually thicker, the layer formed last on the skin constantly raising up those pre- viously secreted, so as at last to constitute a coat of from four to six lines in thickness. The layers nearest the dermis preserve their consistence ; but the more external layers, being bathed in the serous discharge, soften, pu- trefy, change color, assuming a gray or sometimes blackish appearance, and exhale a dreadful fetor. It is (as in pharyngeal diphtheria) very difficult under such circumstances, not to believe that there is extensive sphacelus. I do not say that there are no cases in which gangrene may not attack parts affected with diphtheria: this, in fact, does occur, and particularly in diphtheria of the vulva, as I mentioned when speaking to you of the com- plications of measles. When the disease spreads with rapidity, or when it simultaneously occupies a great many points, there maybe high fever; but generally, there is not much fever, and what there is has a hectic or suppu- rative character. The continuous mode in which the invasion of diphtheria takes place has this peculiarity, that it generally advances from above downwards. Thus, for example, we do not find diphtheria ascending the arm to the shoulder, or proceeding from the neck to the scalp; but, on the contrary, we see it descend from the shoulder to the arm, from the neck to the back, from the belly to the loins, and from the nipple to the rest of the breast. It juts out irregularly, affecting sometimes the shape of points in a backgammon table, the surrounding skin presenting a dull red color. It is very probable that the propagation of the diphtheritic inflammation is accomplished by the irritation induced by the long contact of the serous discharge which bathes the parts as it runs downwards, or is retained by the dressings in particular situations. But this kind of extension of the disease differs very much from its repeti- tion, if I may be allowed so to express myself. It is enough that a point 372 DIVERSITY OF LOCALIZATION IN DIPHTHERIA. of skin or mucous surface is the seat of the pellicular affection, to cause the malady to re])eat itself in several other places simultaneously, under the in- fluence of any slight accidental influence. Thus, as I have already said, cutaneous diphtheria may develop itself in individuals suffering from pseudo- membranous sore throat, and likewise, diphtheria primarily developed on the skin, may become the starting-point of pseudo-membranous pharyngeal and laryngeal affections. There takes place what we see occur in syphilis. What is it-that takes place in that disease? At the point of inoculation, there is produced the specific ulceration, the chancre, and at a longer or shorter interval after the sore is healed, the characteristic constitutional symptoms of pox appear. In cutaneous diphtheria, matters proceed more rapidly, but in a similar manner. An abraded surface has served as a door of admission for the disease, which for some time, remains a local affection: sometimes, it may be destroyed in its locality by energetic treatment at the opportune moment, but too frequently, notwithstanding energetic treatment, and even when we are hoping that the progress of the malady has been arrested, diphtheritic exudations appear on other parts of the body, particularly in the region of the pharynx, the favorite seat of the plastic affection, and the victim dies in a profoundly anaemic state, with the malignant symptoms already de- scribed. Often, even, the patient sinks prior to the manifestation of any new local symptoms. Cutaneous diphtheria, under which term I include diphtheria of the vulva, vagina, and anus, is thus, you see, a much more formidable disease than the croup-producing pharyngeal diphtheria: it is more formidable solely on account of the intensity of the inflammation, which, from its occu- pying a large surface, may lead to deepseated mortification of tissues, often the starting-point of general poisoning of the system, thus constituting that malignant form of the disease to which I have directed your attention. These facts are known, but they are not as yet sufficiently known. I am often called, and you too, gentlemen, will often be called to children suf- fering from pharyngeal diphtheria, more particularly when there is croup, to whom blisters have been applied. Again, when you are in hopes that you have saved a child by tracheotomy, when the tracheal wound was nearly closed, and all seemed going well, you will have the grief to see your patient perish from malignant diphtheria, which may have had its starting-point in an injurious proceeding of the relations, or sometimes of the medical attendants. I cannot, therefore, too often repeat to you: Take care that you do not, for any reason whatever, apply blisters to patients suffering from croup : beware of wounds, beware of the very smallest solutions of continuity, and of leech-bites in persons attacked with diphtheria. When you do find any solutions of continuity, cauterize them vigorously without loss of time, with the solid nitrate of silver, or the solid sulphate of copper: powder them with calomel, white precipitate, or red precipitate: with all possible expedi- tion, modify the morbid action of the affected parts, so as to prevent, as far as that may be possible, the frightful symptoms which will otherwise inev- itably declare themselves. DIPHTHERIA OF THE MOUTH. 373 Diphtheria of the Mouth. [Stomacace.- Watery Chancres.-Scorbutic Gangrene of the Gums.-" Fe- garit" of Spanish Physicians.- Ulcero-Stomatitis: Uleero-Membranous Stomatitis.-Diphtheria of the Gums.] Of all the manifestations of Diph- theria, it has the greatest tendency to remain confined to its first locality.- May be propagated to the Pharynx and Larynx and produce Croup.- May lead to Gangrene.-May be a manifestation of Malignant Diph- theria.-Exceedingly contagious.-Epidemic. Gentlemen : Diphtheria of the mouth was really not known to the physicians of our day till after the publication of Bretonneau's remark- able treatise on diphtheria. In calling the attention of his contemporaries to this disease, the illustrious physician of the school of Tours remarked that it was one of the species of stomacace of the older authors, and of fegarit of the Spaniards, names, he says, which, though different in their etymol- ogy, both signify malignant ulceration of the mouth.* Van Swieten has devoted a special paragraph to it; but he misunderstood its nature, regard- ing it as a scorbutic affection. However, recalling the description which Aretseus has given of malignant ulcers of the tonsils-" tonsillarum ulcera pestifera"-Van Swieten recognizes the connection which exists between the malignant aphthae and the Syrian disease : he admits that the disease is propagated, not only to the pharynx, but also to the respiratory organs. These facts had fallen into oblivion, when they were again brought to light by Bretonneau, who showed that pseudo-membranous stomatitis, pseudo- membranous sore throat, and croup, are identical. In 1818, when the legion of La Vendee was in garrison at Tours, several soldiers were attacked by a particular affection of the gums to which the surgeons gave the name of land scurvy [scorbut de terre]. Within a very short time, nearly the entire legion was attacked : the number of patients was so great that some had to be removed from the surgical to the medical wards, a circumstance which afforded Bretonneau an opportunity of study- ing the disease. At first, he also believed that the disease was scurvy. He perceived, however, that the outbreak could not be ascribed to the influence of diet or locality, and that the condition of the patients presented no trace of scorbutic cachexia : they were strong, vigorous men, in the enjoyment of perfect health, except that they had this particular affection. This scurvy had, in point of fact, stomatitis as its sole manifestation : there were no ecchymoses, no stiff joints, no hemorrhagic tendency, except bleeding from the gums : in a word, there was not found any of the marvellous symp- toms described by authors, particularly by Lind. Bretonneau observed that some of the soldiers affected with the scorbutic gangrene took diphtheritic sore throat, and died of croup. This circumstance led him to reflect on the fact, that in other soldiers of the same legion the tonsils were primarily affected by the plastic inflammation, which exended to the back part of the throat and to the air-passages : he then came to the conclusion that this so-called scorbutic gangrene was nothing else than the pellicular disease occupying the gums, and wearing a particular aspect. At precisely the same period, some cases of croup occurred in the vicinity of the principal barracks occupied by the legion of La Vendee. The physicians of the town * Van Swieten: Chapter, "Del'Angine gangreneuse" commentary on Boer- haave's Aphorism, 816. 374 DIPHTHERIA OF THE MOUTH. affirmed that up to that time they had uot met with a single case in the entire course of their practice : and Bretonneau himself acknowledged that he had only twice seen croup. Ere long, a real epidemic of the disease scourged the town of Tours. Bretonneau, having examined with minute attention the numerous cases which were passing before him, very soon became convinced that the stoma- titis which was then occurring was identical with the disease called gan- grenous sore throat. He assigned to the disease certain characters, which I shall now endeavor to describe to you. After experiencing general discomfort for some days, or still more fre- quently, without anything to announce the coming on of the symptoms, there appear on the free margin of the gums, at the insertion of the teeth, small, yellowish-white, oblong, irregularly rounded patches, forming a sort of border of not more than a millimetre in breadth. The tartar round the neck of, and on the substance of the diseased teeth, is deposited in greater abundance than usual as a grayish, brownish, rusty-looking mud. The gums are gradually destroyed around the sockets of the teeth, in conse- quence of which the teeth become uncovered and loose. The rusty color to which I have adverted is due to the mixture of a certain quantity of blood with the peculiar pseudo-membranous exudation from the gums. The slightest touch causes the affected parts to bleed, and even by gently separating the lips, you will cause little drops of blood to fall down. The gums are painful, and to a certain extent swollen, but they never present the blue fungous appearance which they have in scurvy. As the disease advances, the false membranes extend, become livid or black, seem as if deeply sunk, and are surrounded by a red border encircling them like a cushion, so that they simulate ill-conditioned ulcers. But there is no ulcer- ation ; and the false membranes are easily detached from the mucous mem- brane which they cover. When, however, the false membranes are removed, they are speedily replaced by others. The lymphatic glands of the sub- maxillary region, which from the onset of the disease had begun to be swollen and painful, particularly when touched, now become more swollen, and embrace the neighboring parts in the tumefaction. A considerable flow of saliva and'sanious serosity wets and stains the linen of the patient: this discharge continues during sleep. The breath exhales an intolerably fetid odor: this fetor, combined with the appearance of the affected parts, gives the disease a very great resemblance to gangrene. But here, again, appearances are deceitful. There is here no more gangrene than there is in pharyngeal diphtheria: nevertheless, just as I was careful to tell you, that in some rare instances pseudo-membranous sore throat leads to sphacelus of subjacent tissues, so must I state, that plastic stomatitis may lead to a similar result. I must add, that this consecutive gangrene is a much more common sequel of buccal than of pharyngeal diphtheria. It is far more frequently met with in hospital than in private practice: indeed, in the latter, I have never yet seen it. There is no period of life at which diphtheria of the mouth does not occur; but it is a rare affection among young children, and exceedingly rare among infants at the breast. Bretonneau's first observations, as you are aware, were made on soldiers, consequently upon adults. It is, in general, at the socket of a diseased tooth that diphtheria of the mouth begins, and thence it proceeds to invade the rest of the gums. There is no form of diphtheria which has so strong a disposition as diph- theria of the mouth to localize itself without spreading to neighboring parts. Thus, although diphtheria of the pharynx has a tendency to advance from one place to another, like lava flowing from a crater, diphtheria of the gums DIPHTHERIA OF THE MOUTH. 375 may remain stationary for some months. It would, however, be a mistake to believe that it never extends. Not unfrequently the malady is commu- nicated from the . gums to the mucous membrane of the cheeks, and inside of the lips, forming a junction with the white spots, which then soon increase in size. Afterwards, in their turn, the veil of the palate and the tonsils may become implicated, as in cases observed by Bretonneau; the malady may then advance by the line of march which I have already pointed out, invading the larynx and trachea, and at last causing death by croup. I shall now textually quote to you one of Bretonneau's illustrations. "At the end of the epidemic," says Bretonneau, " eight children, between nine and ten years of age, who slept in the same dormitory at the Orphan Asylum, were attacked during the same week with scorbutic gangrene of the gums. I have noted a peculiarity which I am quite unable to explain, and which no circumstance of which I am aware offers any plausible ex- planation : all the eight were affected on the right side. From the second day of the invasion of the disease, three had the corresponding tonsil swollen and covered with pellicular deposit." " Is it not possible," adds the author, " that the diphtheritic inflammation might have rapidly reached the larynx, had not its progress been arrested by the application of strong hydrochloric acid, the effect of which was so prompt and efficacious, that in a few hours after it was first applied the swelling of the lymphatic glands was sensibly diminished ?"* It is when diphtheria reaches the inside of the cheeks that it has a ten- dency to terminate in gangrene. After remaining confined to the gums for one or several months, after remaining confined to the mucous membrane of the mouth for a period of which it is impossbile to state the limits, an oedemato-phlegmonous swelling of the face supervenes : the skin of the face becomes red, the tissues acquire considerable hardness, and ere long gan- grene of the mouth, with all its characteristics, involves the cheek, as well as the gum which was the starting-point of the evil. The identity of buccal and pharyngeal diphtheria with croup has been established beyond dispute by the researches of Bretonneau. It is fully proved by the fact, that the plastic affection of the gums may be propagated to the pharynx and larynx. Moreover, the case which I quoted to you of the infant who died almost simultaneously with the mother from malignant diphtheria, of which the first appearance was in the gums, also shows that there exists that complete identity in which I believe. One of my most distinguished colleagues, Dr. Jules Bergeron, physician to the Hopital Sainte-Eugenie, in an interesting and conscientious work,f while he holds that the disease he describes is the same as that observed by Bretonneau in 1818, denies that ulcerous stomatitis is a diphtheritic affection. He rests his opinion upon two facts, viz., that in none of his cases of ulcerous stoma- titis-all carefully observed-did the malady ever propagate itself beyond the gums, and that in none were there any symptoms of toxaemia. Against these arguments may be placed the cases observed by Bretonneau, in which the kind of propagation was seen of which Bergeron denies the occurrence. But by reading the lucidly drawn descriptions of Dr. Bergeron, it is easy to satisfy oneself that the ulcerous stomatitis of which he speaks was very different from the plastic stomatitis of the legion of La Vendee : the single fact of the existence of ulcerations would suffice to establish this * Bretonneau : Des Inflammations Speciales du Tissu Muqueux, et en particulier de la Diphtherite, p. 127. Paris, 1826. j- Bergeron (Jules): Stomatite Ulcereuse des Soldats. [Recueil de Memoires de Medecine Militaire.'] Paris, 1859. 376 NATURE OF DIPHTHERIA. difference-you can, I say, find the proof of the correctness of this state- ment in Bergeron's treatise, and in other works subsequently published on the subject. In diphtheria of the gums or mouth, the plastic exudation leaves uninjured the mucous membrane which it covers; or, at all events, there is nothing like real ulceration. Apart from the possibility of the propagation of the disease to the pharynx and larynx, apart perhaps from that which shows itself as the first symptom of malignant diphtheria, plastic stomatitis is identical in its nature with other diphtheritic affections. This identity is further shown by the con- tagiousness of both affections. The plastic affection of the gums is not only communicated as stomatitis, but likewise as pharyngeal, or even as malig- nant diphtheria. Thus, as I have told you, in the Tours epidemic of 1818, no one could recollect seeing cases of pseudo-membranous sore throat or croup prior to the arrival of the legion of La Vendee, which brought diphtheria to the town. I have also told you that the first cases occurred in the neighbor- hood of the principal barracks, which were occupied by the soldiers of that legion. In a family, one member of whom was attacked with pseudo-mem- branous stomatitis, some were similarly affected, while others took pharyn- geal diphtheria, croup, and cutaneous diphtheria. Such facts admit of being more easily ascertained when they occur in small districts, where physicians can trace the malady back to its source, where, so to speak, they at a glance can understand what is going on, and follow, step by step, the invading march of the epidemic. Nature of Diphtheria.-Contagion.-Alteration of the Blood.-Albuminuria. Gentlemen: At the period when Bretonneau wrote his treatise on diphtheria, medicine, French medicine at least-was under the dominion of the physiological doctrines of Broussais: his theory of inflammation reigned supreme throughout the entire domain of pathology, so that in all diseases, inflammation was regarded as the only element of which it was necessary to take account. Pinel, however, had shown that in different or- ganic tissues, inflammation underwent very characteristic changes: the illustrious author of the Nosographie Philosophique had already thrown a great deal of light upon the history of diseases, and given a new impulse to the spirit of observation. Bretonneau, proceeding further than Pinel, in his turn showed, that the various inflammatory alterations, and the phe- nomena which accompany them, do not exclusively depend upon the spe- cialty of the affected tissues: he demonstrated in his remarkable works on diphtheria and dothinenteria that the specific character of the inflamma- tion, much more than its intensity, and much more than the nature of the tissue in which it is seated, exerts an influence upon the functional disturb- ance produced by each inflammatory lesion: it is, he said, to the specific character of the inflammation that the duration, severity, and danger of most pyrexise are attributable. The malady which we are now studying was not regarded as an excep- tion to the absolute rule which it was attempted to lay down. In pseudo- membranous sore throat and in croup, nothing was seen but an inflamma- tion of the throat or larynx, which it was deemed essential to treat by anti- phlogistic measures. Here, unquestionably, the inflammatory element may play its part: but this, so far from being the chief part, is quite subordi- nate ; exactly as in small-pox, and measles, as well as in other diseases, it NATURE OF DIPHTHERIA. 377 is subordinate to the nature of the presiding cause, which imposes on it its peculiar stamp. There is, however, an essential difference between the diseases which I have just named and diphtheria: this difference consists in the greater im- portance which in diphtheria attaches to the local affection. In small-pox for example, we look at the pustules chiefly in relation to their diagnostic and prognostic significance, but in diphtheria, we regard the local manifes- tations from the treatment point of view. In diphtheria, it is just as in malignant pustule, in which malady, by making a direct attack upon the local affection, we stop the progress of the general disease of which the pus- tule is the first manifestation. So is it also in diphtheria : by energetically treating the local affection, as soon as it shows itself, we arrest its progress, and prevent the occurrence of ulterior symptoms. I shall return to this point, when I come to discuss the subject of treatment. • Whatever local manifestations, and whatever general forms diphtheria may assume, it is always, in its essential nature, the same disease: it is the same disease whether it affect the mucous membranes or the skin ; whether it appear as a pharyngeal, laryngeal, or bronchial affection, as stomatitis, as plastic coryza, or as a cutaneous, vulvar, anal, or preputial affection, it is the same. The diversity of aspect presented by the local affections de- pends solely upon the diversity in the nature of the tissues in which the morbid action shows itself: the different manifestations all originate in one sole cause. The indisputable correctness of this statement is shown by what takes place in epidemics, when we see diphtheria transmitted from person to person, assuming a variety of forms, and exhibiting great di- versity in its localization ; when, for instance, we see a patient who is af- fected with diphtheria of the gums communicate to other persons pseudo- membranous sore throat, croup, cutaneous diphtheria, or some other form of the pellicular disease. Dr. Guersant mentions a case in which diph- theria of the prepuce in a child was the starting-point of pseudo-mem- branous sore throat in the brother and the father. Looking at the great differences which there are in the symptoms pre- sented by the different forms of the disease, it might seem that that form which kills by attacking the air-passages-simple or genuine diphtheria,- and that which kills by general poisoning-malignant diphtheria-are in their nature very distinct from one another. But it is not so, gentlemen ; under this diversity of form, just as amid the variety of the local affections, it is always the same disease which we encounter: it is always diphtheria, just as it is always small-pox, whether the form be confluent or distinct, mild or malignant. The transformations which the disease undergoes in accordance with the nature of the epidemic depend on I know not what- on a something which we agree to call the character of the epidemic [genie epidemique'] : this diversity of form met with in the same epidemic depends upon the natural or acquired peculiarity of the individual. From this point of view, the comparison which I have made between diphtheria and small-pox appears to me all the more appropriate, that, besides the simple and malignant forms of which I have spoken, the pellicular disease assumes an aspect which is analogous to the relation which modified small-pox bears to small-pox. Indeed, in some epidemics, individuals are seen to take sore throats, which, in respect of anatomical characters, seem to be of the com- mon membranous kind, such as result from herpes of the pharynx, or even simple sore throat; while they are in reality diphtheritic sore throats, modi- fied in a remarkable manner. That which makes my comparison thoroughly appropriate, that which proves the identity of the nature of the different forms of diphtheria is, that each of them, in passing from one individual 378 NATURE OF DIPHTHERIA. to another, may declare itself under a particular form : modified diphthe- ritic sore throat, for example, may give either simple or malignant diph- theria, just as modified small-pox may give distinct or confluent small-pox; and vice versa. At the meeting of the Medical Society of the Parisian Hospitals, held on the 25th August, 1858, my honorable colleague Dr. Alphonse Guerard stated the following circumstances, which, within a period of about six weeks, he had recently observed in one family. A child died of laryngeal croup: two days afterwards, two young girls took ery- thematous sore throat, and were attended by our lamented brother, Dr. Gillette. Some days later, the father, aged forty-five, a patient of Dr. Guerard, took a pseudo-membranous pharyngeal sore throat. Two other children of the family were next attacked, one with simple, and the other with membranous sore throat. A similar history was communicated by Dr. Henri Roger to Dr. Peter, who has published it in his inaugural thesis. " G., aged two months, was seized with membranous sore throat on the 17th May, which proved fatal on the 22d. During the evening of the 21st, the mother, a woman twenty-two years of age, had general discomfort and fever. There was also sore throat; and within twenty-four hours, a whitish speck appeared on the right tonsil. On the following day, false membrane was observed on both tonsils. The submaxillary glands were engorged, and chaps round the nipple were covered with pellicular deposit. During the following days, the general and local symptoms became more severe. Ultimately, there was a gradual and slow amendment. At the beginning of June, the false membranes had completely disappeared; but there was an abscess in the right tonsil. The woman was, however, quite well by the 11th June. " The child's nurse, a woman aged 33, was seized with sore throat, which was severe, but not pseudo-membranous. In this case, the malady con- tinued for thirteen days-that is, from the 23d May to the 4th June. "The father of the child G., a man of 35 years of age, had a simple sore throat of average severity, which lasted four days-that is, from the 25th to the 29th June. " The child's grandfather and grandmother, who went daily to see their children, particularly the grandmother, who had attended upon them, had very mild sore throats. " A lady residing in the neighborhood, a friend of the family, who came often to the house, was attacked by laryngitis. " The cook, a woman above forty, had no symptom of sore throat."* Dr. Peter follows up this group of cases with some remarks in which I cordially concur. He then, in contrast with the cases just quoted, in which the severity of the cases diminished progressively in transmission from chil- dren to adults, mentions another series of cases, in which there was an in- verse progress of the malady, in which it passed from adults to a child, and from that child to an oldish man. The following is the history of the disease in the family in question. The husband of the female servant was the first who took ill: he com- municated pseudo-membranous sore throat to his wife : she recovered. Six days later, the child of the master of the house, twenty-six months old, was attacked by pharyngeal diphtheria : then, on the twelfth day, the larynx was invaded; and next day, when Dr. Gillette did me the honor to consult with me on the case, the croup was far advanced. In the evening, Dr. * Peter (Michel) : Recherche.® stir la Diphtherite et le Croup. Paris, 1859. CONTAGION OF DIPHTHERIA. 379 Peter performed tracheotomy ; but this did not save the child, who died on the fourth day after the operation. It was from this child, when he was attending upon him, that our lamented brother Gillette took diphtheria, from the consequent croup of which he died, without tracheotomy having been tried, as the pseudo-mem- branous exudation had reached the bronchial tubes. Diphtheria, then, is pre-eminently a specific disease, the different local and general forms of which, constituting merely varieties of a species, are attributable to the action of the same morbific principle, a specific morbid poison: in a word, it is a pestilential disease. Like all diseases of an un- questionably specific character, it is contagious ; and perhaps is inoculable. The cases, however, which have been brought forward in proof of the pos- sibility of inoculating diphtheria, particularly those communicated to the Hospitals' Medical Society by Dr. Bergeron, are very open to be called in question, and the experiments performed with a view to arrive at a rigor- ous demonstration of facts have as yet been barren of results. I am not speaking of the experiments made on animals, for it is admitted that in respect of inoculation in the human subject, no conclusions can be derived from experiments made on animals : I am only referring at present to the inoculation of the disease from man to man. In 1828,1 tried ineffectually to inoculate myself with diphtheria, by means of punctures on the left arm, tonsils, and veil of the palate, made with a lancet moistened by contact with a false membrane which I had just removed from a diphtheritic sore. Dr. Peter, in the excellent work which I have already quoted several times, states that upon three occasions he repeated the same experiment on him- self without obtaining any result. In the first instance, when performing tracheotomy on a child, he received on the surface of the cornea of the left eye, a semi-liquid pseudo-membranous exudation, which for a moment cov- ered the globe of the eye, and the most fluid part of which insinuated itself under the eyelids : he did not wash the eye, yet no consequences followed the occurrence described. On the second occasion, he made three punc- tures in the lower lip, with a lancet moistened with semi-fluid diphtheritic exudation : he experienced no derangement of health from the proceeding. On the third occasion, this daring experimenter painted the tonsils, the pillars of the veil of the palate, and the back of the pharynx by means of a dossil of charpie soaked in diphtheritic matter: again the result was negative. It therefore seems possible, gentlemen, from these experiments, that diphtheria is not more inoculable than measles, scarlatina, and hoop- ing-cough, maladies the contagious character of which no one doubts. If any one, in times past, has for a moment denied the contagious char- acter of diphtheria, forgetting the observations of our predecessors, among others those of Rosen, and long before him, those of Cortesius, and De Wedel, no one in the present day could dispute that it is contagious. Bre- tonneau, in his treatise on diphtheria, called attention to this point, and again, in a more special manner, returned to the subject, in his last work, which appeared in the " Archives Generales de Medecine" for the year 1855. Numerous facts are therein collected from the history of epidemics in all quarters. Nevertheless, it is not always easy to perceive the manner in which the disease has been transmitted from one place to another. In some instances, however, one can trace it back to its origin ; and that can be done in the following case, the history of which is undoubtedly au- thentic. The epidemic of diphtheria which prevailed at Fresnay-le-Ravier, arron- dissement of Nevers, in 1858, had as its starting-point a child who had been 380 ALBUMINURIA IN DIPHTHERIA. brought from Paris. That child died, also the infant of the nurse, and the nurse herself. The scourage then broke out in the village. Once diphtheria enters a house, it has an undoubted tendency to propa- gate itself by contact from individual to individual. How frequently we see almost all the children in a family attacked in succession, while the father, mother, and attendants on the sick are also brought more or less under the influence of the disease! I have given you examples of this; and, as you are aware, the medical profession has paid a heavy tribute in life to the contagious power of this frightful disease. I have already men- tioned Valleix, Henri Blache, and Gillette, to which list, too long though it be, there remain, I doubt not, other names to be added. It appears, then, that the question of the contagious character of diph- theria is at present generally answered in the affirmative. It was lately under discussion in the Hospitals' Medical Society, and the subject of an excellent communication by Dr. Henri Roger, in which his object was to establish, on the basis of a series of authentic and rigorously observed cases, not only the contagious character of diphtheria, but likewise the duration of the incubation of the diphtheritic poison. From these researches, it seems that the period of incubation generally ranges between two and seven days: you must bear in mind, however, that in consequence of the impossi- bility of inoculating diphtheria, this statement must be regarded as only a near approximation to the truth. I have told you, that diphtheria, in its malignant form, kills after the manner of septic diseases, by a sort of general and complete poisoning of the system. This poisoning shows itself during life by the local and gen- eral symptoms which I have described : it is characterized by a peculiar alteration in the blood, which is found on necroscopic observation; also by albumimiria, a functional disturbance, met with in a great number of septic diseases, such as variola, scarlatina, dothinenteria, and cholera; and finally, it is characterized by paralytic complications, to which, from their great importance, I mean to dedicate an entire lecture. The alteration of the blood, to which I to-day call your attention, was first pointed out by my young colleague, Dr. Millard, in his excellent inaugural thesis ;* and it has more recently been discussed in Dr. Peter's work, pub- lished in 1859. At the autopsy of six persons who died of croup compli- cated with plastic coryza, a complication which I mentioned as occurring in malignant diphtheria, Dr. Millard five times met with this alteration of the blood, which till then had not been described by any one. I must add that Dr. Millard states that the sixth case was too imperfectly observed to justify a negative conclusion in respect of it. This alteration of the blood consists in a very marked change in its color: in place of being of a more or less deep red, it is brown. Dr. Millard compares this to the juice of plums, and to the juice of liquorice: he says it stains the fingers almost as much as sepia. Dr. Peter compares it to water colored by soot. The vis- cera and mucous membranes being impregnated with it, present a dirty hue, which is quite characteristic. This blood is turbid, and somewhat muddy : the clots formed are soft, and somewhat resemble the overcooked juice of the grape [resine trop-cuit]. The arteries, instead of being found empty after death, as is generally the case, contain nearly as much blood as the veins. I have now reached the subject of albuminuria. Gentlemen, several years ago, an English physician, Dr. Wade, of Birmingham, announced that he had found albumen in the urine of diphtheritic patients, and also that its * Millard: Sur la Tracheotornie dans le Croup. Paris, 1858. ALBUMINURIA IN DIPHTHERIA. 381 presence was a frequent phenomenon in mortal cases. He supported his own experience by quoting that of his colleagues, mentioning that this fact had been observed by several physicians, and among others by Dr. James, who published an interesting account of an epidemic of croup in the "Med- ical Times." Dr. Wade states that in consequence of his having commu- nicated his observations to the Royal Medical and Chirurgical Society, confirmatory cases were at once brought forward by Dr. Robbins and others. This discovery, from having been originally published in the "Midland Quarterly Journal of Medical Science," a periodical little circulated on this side the Straits of Dover, remained for a long time unknown in France. Like everybody else, I was ignorant of the discovery, when there fell into my hands an unpublished paper, by Dr. Abeille, who was the first to my knowledge to mention diphtheria among the diseases in which we may meet with albuminuria. Since that time, I have lost no opportunity of looking for albumen, which I have several times found in the urine of diphtheritic patients in the clinical wards, and did not fail to notice in my clinical lectures during 1857. In a lecture delivered on the 23d June, 1858, Dr. G. See, ignorant of the researches of the English physicians and of Dr. Abeille, in a more particular manner called general attention to the fre- quency of albuminuria occurring in malignant sore throat, and in croup both before and after tracheotomy. He stated that in his wards in the Children's Hospital, the urine of all the diphtheritic patients was examined for albumen every day, and that at least in one-third of the cases, it was found in notable quantity. It is, therefore, as Dr. Wade originally stated, and as I have verified before you, very common to find albumen in the urine of diphtheritic patients. The phenomenon has been explained in several ways. Some have looked on the cause as possibly of a complex character, thinking that the presence of albumen in the blood might depend in some cases upon passive transient congestion of the kidneys produced by asphyxia in croup, and the conse- quent stasis of the blood. This theory is very open to objections, even in the exceptional cases to which attempts have been made to apply it. With the majority of physicians, I believe that the occurrence of albumen in the urine of diphtheritic patients is dependent upon the general state of the system : we find here, but cannot explain why, the same condition we meet in such septic diseases as small-pox, scarlatina, and dothinenteria. In some cases, albumen is found in the urine from the very onset of the dis- ease ; the quantity obtained by treatment with heat and nitric acid varies considerably in the same individual from one day to another: sometimes, its appearance is intermittent. You may remember a case of this kind which occurred in a young woman who lay in bed No. 9 of St. Bernard's Ward, the history of which I shall bring before you in relation to the subject of diphtheritic paralysis; you will remember that the varia- tions in the quantity of albumen which we found in the urine of this patient did not in any way correspond with the increase or decrease of the para- lytic symptoms, and that it was useless to attempt to form a prognosis from what was seen in the test-tube. In point of fact, however interesting this phenomenon may be, it is impossible in the present state of our knowledge to arrive at any absolute induction from it. a It is quite correct to say, in general terms, that in severe cases of diphtheria, albuminuria is usually met with : but the exceptions to this rule are numerous. Again, we some- times meet with albuminuria in slight, and find that it is absent in serious, cases. An attempt has been made to explain by albuminuria the paralytic affections regarding which I am, forthwith, going to address you. I may remark, however, that albuminuria is not a constant symptom in that class 382 PARALYSIS IN DIPHTHERIA. of cases ; and also, that the paralytic affections incident to diphtheria do not admit of comparison with the symptoms of disturbance of the nervous system which supervene in the course of acute or chronic albuminuria, which are characterized by convulsions or coma, and, with the exception of amaurosis, never by paralysis. One word more on this subject. Al- though Dr. Wade states that he has never seen dropsy accompany diph- theritic albuminuria, dropsical affections are, according to Dr. G. See, sometimes met with, though much more rarely, he says, than in scarlatina. For my part, I have met with but few examples; and so far as I can make a statement on such a point from memory, I should say that I have not met with this anasarca in one case in twenty. To sum up : The presence of albumen in the urine of diphtheritic patients, whether the disease be in the form of pseudo-membranous sore throat, croup, or cutaneous diphtheria, is a frequent occurrence, but one which in the actual state of our knowledge has only a limited signification in relation to prognosis and treatment. It is, however, impossible, to deny that it is the expression of a great disturbance of the organism, produced by the morbific principle which engenders diphtheria. Paralysis in Diphtheria. Not a New Disease.- The Mild Form.-Symptoms.-Paralysis of the Veil of the Palate, of the Senses, Limbs, and of the Muscles of Organic Life.- Death by Suffocation, by Strangling.- The Aggravated Form.-Ataxo- . adynamic Symptoms.- The Gravity of the Paralysis bears neither any Relation to the Intensity or Duration of the Pseudo-membranous Affec- tion, nor to the Albuminuria.-This kind of Paralysis is the Result of Poisoning.- Treatment. Gentlemen : We stopped for a long time when going round St. Bernard's Ward beside a young woman who was stretched out on an easy-chair, whence it was impossible for her to raise herself. This patient, who occupied bed No. 10 of that ward, had been struck with paralysis three months previ- ously. Under our own eyes we saw the gradual development of the symp- toms. She now presents a remarkable example of the paralysis consecutive to diphtheria, an affection which certainly is not new, but which has not, till very recently, been accurately studied. This case, which gives me an opportunity of addressing you to-day on this subject, is so interesting, that I do not hesitate to lay it before you with some minuteness of detail. The patient, aged 28, came into the clinical wards on the 6th August, 1859. Eight days previously she had had feel- ings of general discomfort, and had suffered from severe headache : she also had had fever, sore throat, and profuse sweating: on the day following she had vomiting and loss of appetite. There was a special circumstance connected with this young woman which it is important to note: she had, only fifteen days before the seizure now described, left our wards, where she had been under treatment for lumbago: she had, during that period* occupied the bed adjoining that of a woman with diphtheria, whose infant had died from croup. It was probably from them that she contracted the disease which brought her back to the Hotel- Dieu. At the morning visit on the 7th August, I saw that there was very ex- tensive plastic sore throat: the uvula and tonsils were entirely covered with false membranes, and presented more than one grayish-white surface. I PARALYSIS IN DIPHTHERIA. 383 immediately cauterized the affected parts with hydrochloric acid. I pre- scribed insufflations of alum, and directed them to be used several times during the twenty-four hours: also a julep, containing six grammes [93 grains], of the perchloride of iron ; and also the powder of cinchona in in- fusion of coffee. Next day I was shown a very thick false membrane which had been detached from the throat: this diphtheritic deposit was in length two cen- timetres and a half, and in breadth one centimetre. On the free surface traces were visible of the cauterization of the previous evening, and at the part where the eschar adhered to the mucous membrane, the latter was furrowed by fine red arborizations. In the cavity of the mouth the false membrane was less abundant, and was found only on the uvula and poste- rior pillars of the veil of the palate. The cervical glands, particularly those of the right side, were engorged. On examining the urine we found that it contained a considerable quantity of albumen. The julep with perchloride of iron was continued, and the quantity of the latter was increased to eight grammes [two drachms and four grains] : I then introduced into the throat water strongly charged with tannin, using the apparatus constructed in accordance with the suggestions of Dr. Sales-Girons for the inhalation of medicated waters. During the night of the 8th and 9th August the patient was seized with a fit of difficult breathing, which made it necessary to call the pupil on duty, who removed from the pharynx a thick false membrane, which was the cause of the attack. From the date of this occurrence the false membrane became from day to day thinner and less extensive. On the 11th, after having removed a very thin layer, I cauterized with hydrochloric acid the surface which had been covered by false membrane; and on the 16th there only remained a few small white spots. The diphtheria seemed to be per- manently stopped. Nevertheless, the perchloride of iron was taken to the extent of ten grammes [155 grains] a day up to the 23d of August, after which it was discontinued. The urine, however, when treated by heat and nitric acid, still yielded a considerable precipitate of albumen. To state at once all that refers to this symptom, from 15th August to the 12th September, though great variations occurred in the amount of albuminous precipitate, there was a progressive diminution, and on the 12th September I noted on the report-sheet that there was "very little albumen in the urine;" but within a few days it reappeared in as great abundance as at first. This recrudescence of the albuminuria coincided with the manifestation on the 14th of the special nervous symptoms on which I am going to make some remarks. For three days the albuminous precipitate was very abundant: on 17th September there was none, but on the 18th there was a slight trace : this reappearance of albumen was very transient, and by the 20th September the albuminuria had finally ceased. From the 12th August-the malady being then in its ninth day-the uvula was quite free from false membrane, but on the right tonsil there was some, and on the left, an exceedingly slight trace: elsewhere, there was none. But a symptom existed which claimed my serious attention: this was a nasal tone of voice, indicating incipient paralysis of the veil of the palate: from day to day, this snivelling increased. On the 15th, on trying the strength of the patient, by Dr. Burq's dynamometer, I found that the pressure of the right hand was 27, and of the left, 22 kilogrammes. Three days later, the paralysis of the veil of the palate had increased : drinks and liquid food returned by the nose. On 20th August, the young woman com- plained of general weakness, and of formication in the feet: she marked on 384 PARALYSIS IN DIPHTHERIA. the dynamometer 23 kilogrammes by the right, and 20 by the left hand. On the 23d, the hands were benumbed, and, like the feet, were the seat of formication : she could not walk without stumbling. On the 25th, I as- certained that she was in an anaesthetic state. I could prick her without her being aware of it. On applying the aesthesimeter to the dorsal surface of the left forearm, she did not feel distinctly the two points of the instru- ment when six centimetres apart from one another. The arms were ex- tended, and the hands were in a state of constant tremulous motion.' Not only were fluids swallowed with difficulty, but even solid food caused pain in passing the isthmus of the fauces-to use the expression of the patient- the morsels remained sticking in the throat. For some days, this dysphagia went on increasing in severity. On 31st August, new symptoms arose. When this unfortunate young woman was breathing, we heard a slight whistling sound during inspiration, like that produced in persons suffering from what is called oedema of the glottis. From the previous evening, she had been suffering much from difficulty of breathing, and the inspirations were 54 in the minute. On examining the chest by auscultation and per- cussion, we found no abnormal condition. On 2d September, the lips and tongue were affected with paralysis. The patient felt numbness and formi- cation, and she had difficulty in articulating. The difficulty in speaking increased, as well as the dyspnoea. The gums wrere insensible, and the teeth ceased to feel the food which they masticated. I then had recourse to elec- tricity, which I caused to be applied to the anterior and lateral parts of the neck ; and likewise over the epigastric region, having a suspicion that the dyspnoea was referable to the diaphragm, which was paralyzed like the other muscles. On the fifth day of this treatment, the patient told me that she could swallow a.nd breathe more easily. She was, however, very far from having got rid of her untoward symptoms. On 11th September, her sight became affected. Vision was dim ; she could not read, and the letters looked as if in confusion. The difficulty of articulating had become still more marked: the hands, but not the feet, continued to be benumbed. It was at this period, let me remind you, that the albumen reappeared in considerable quantity in the urine after having greatly diminished: it was also at this period, that is to say about the 14th of September, that the pa- tient was seized during the visit with the nervous symptoms to which I have already alluded : she had been complaining since the morning of a tremu- lous movement of the hands. Just as I was leaving her bed, I perceived her all at once become affected with violent convulsive movements in both arms, the eyelids, and muscles of the eye: the globe of the eye was turned upwards. These convulsions lasted for more than an hour, consciousness remaining perfect during the whole time. This woman had never had pre- viously any nervous attack. I prescribed the following potion : mint water 80 grammes [about 22 fluid drachms] ; syrup of ether, 40 grammes [about 11 fluid drachms] ; musk, 1 gramme [151 grains]. Next day, she was very calm. During the night of the 15th and 16th, the convulsions returned, affecting on this occasion the muscles of the face and jaw. At the visit, I observed great dyspnoea, and much difficulty in articulating: there was, however, less dysphagia. The left leg was much weaker than the right, and bent under the weight of the body. There was no loss of power in the upper extremities, but they continued to be the seat of formication. On 22d September, both legs were affected with feebleness, and to such a degree as to render both walking and standing impossible: the evacuation of the bowels was accomplished with great difficulty. The degree of feebleness and accompanying numbness was variable. Thus, while on the 22d, the patient was quite unaware of the existence of her toes, next day that dis- PARALYSIS IN DIPHTHERIA. 385 agreeable state had passed away. There was, however, a decided increase in the weakness of the legs. On the 26th September, she was completely paraplegic: there was vesical tenesmus, then difficulty in micturition-a true paralysis of the bladder. The dyspnoea, difficulty in passing urine, and impeded articulation gradually diminished ; and to-day you have seen the patient breathe, swallow, and speak with ease. The employment of elec- tricity was continued ; it was applied in succession to the parts affected with paralysis. From 1st October, the numbness of the legs began to diminish ; and they gradually recovered their power. On the 7th, the patient could get up and sit on the side of her bed, although she was still unable to walk. On the 11th, in tottering fashion, she began to take a few steps: when she walked, she did not feel the ground under her feet. It was difficult, gentlemen, in this case, not to recognize the relation be- tween the paralytic symptoms which we saw develop themselves under our own eyes, and the diphtheria with which the young woman was still af- fected when they showed themselves. If cases always presented themselves to physiciaiis in this clear form, it is probable that diphtheritic paralysis could not have escaped notice: for assuredly the malady is not new, as some have supposed. What has happened in connection with it, has happened in relation to many other morbid conditions. Albuminuria, which we have only been acquainted with for a few years, is now quite commonly met with. I may say the same in respect of leucocythemia: indeed this example is particu- larly striking, for though the affection was till the other day quite un- known, there is now not an hospital in which cases of it are not met with. Albuminuria and leucocythemia are not new affections, nor are they more common now than in former times, but in the present day, they are recog- nized when met with, whereas formerly, they occurred without attracting attention : the researches of Bright drew our attention to the former, and the latter has been brought under our notice by Bennett, Virchow, E. Vidal, and Magnus Huss. Precisely the same thing has occurred in respect of the paralysis attendant upon diphtheria. As it does not in general su- pervene till a period somewhat remote from the manifestation of the local characteristics of the pellicular malady, it is easy to see how its origin and cause have not always been understood. When we refer to the historical records which have come down to us, descriptive of the JIuZ Egyptiaque-very ancient records dating back to the times of Aretseus, we find only exceedingly slight references to the consecu- tive paralysis. Some distinctly mention the extreme debility which fol- lows diphtheria, but strictly speaking no one says anything of paralysis. Its existence, however, was categorically stated by three authors-Ghisi, Chomel, and Samuel Bard-at the middle and end of last century. All the three completely establish the correlation of paralysis with diphtheria. The case related by Ghisi, in his second medical letter upon the epidemic sore throat which prevailed at Cremona in 1747 and 1748, is that of his own son, a child a little under eight years of age. The following are the concluding sentences of the narrative : "Leaving to the patience and skill of M. Ch. Scotti, doctor in surgery, the treatment of large ulcers occupying both tonsils, and part of the veil of the palate and uvula, I also intrusted to him the treatment of a large pain- ful tumor, which, at the very time that the interior of the throat had got nearly well, began to point externally and to form an abscess a little below the angle of the jaw, under the mastoid muscle. I left to nature the cure of the strange consequences of the disease, consequences which had been re- marked in many who had already recovered, and which continued for about vol. i.-25 386 PARALYSIS IN DIPHTHERIA. a month after recovery from the sore throat and abscess. During that period, the child spoke through his nose; and food, particularly that which was least solid, returned through the nares, in place of passing down the gullet." Also in 1748, Chomel, a French physician, observed in two patients, paralysis consequent upon gangrenous sore throat. In one of these cases, it was unquestionably the same paralysis of the veil of the palate which Ghisi pointed out. "The patient," says Chomel. "had not quite com- menced convalescence at the forty-fifth day of the disease, having still diffi- culty in articulating, speaking through the nose, and having the uvula pen- dulous." In the other case, however, the complications were different from paralysis of the veil of the palate: " the patient became squint-eyed and deformed ; but day by day, as his strength returned, he regained his natural appearance." Samuel Bard, who has written an account of the epidemic sore throat which, in 1771, prevailed in the town and province of New York, describes the case of a little girl, two and a half years old, who recovered from an attack of suffocative sore throat, and cutaneous diphtheria consequent upon the application of blisters; but who retained paralysis of the veil of the palate and weakness of the legs. "The larynx," says Dr. Bard, "retained a special sensibility in respect of liquids: whenever she attempted to drink, she was seized with a fit of coughing, yet she was able to swallow solid food without any difficulty. These symptoms passed off, with the exception of weakness and aphonia, which continued for some time longer. In the second month, she could with difficulty walk alone, or raise her voice above a whisper." These cases had remained unknown. Bretonneau, even, in his treatise on diphtheria, gave a translation of Ghisi's letter and Samuel Ward's obser- vations without stopping to notice the point now before us. My illustrious master's attention had not then been called to the subject: in the epidemic with which he had just been engaged, he had not seen any cases of diph- theritic paralysis; nor did he remember to have met with any cases prior to 1843. The first patient in whom he met with it was Dr. Herpin, a surgeon to the hospital of Tours. Bretonneau published this case, exactly as it was communicated to him by Dr. Herpin, in his paper on the means of preventing the development and progress of diphtheria, which appeared in the "Archives Generales de Medecine" for January and September, 1855. From that time the occurrence of paralysis as a sequal of diphtheria was a fact completely established in the minds of the physicians of the school of Tours; but at Paris, the subject was almost unnoticed, or at least it was not till long after its existence had been pointed out, that the relationship between the paralytic affections and the disease which produced them was fully appreciated. Eight years ago, I and others were struck by the frequency with which paralysis of the veil of the palate occurred in persons who had had diph- theria. The patients, adults and children, had a nasal tone of voice, and great difficulty in swallowing. In endeavoring to explain these cases, I imagined that the paralysis depended upon a special modification of the veil of the palate produced by the plastic inflammation, a modification in virtue of which the muscular fibre constituting part of that sturucture, for a certain time, loses its normal contractility. This was the explanation given by my friend Dr. Lasegue and me in our paper on the subject published in the " Union Medicale" for 9th October, 1854. As that paper referred only to paralysis of the veil of the palate, our explanation was to a certain ex- tent admissible, for one could compare what happened in diphtheritic sore PARALYSIS IN DIPHTHERIA. 387 throat with what sometimes occurs in purely inflammatory sore throat, in which we also meet with this consecutive paralysis; and, speaking in more general terms, with what occurs in all muscular tissue which has been for a time the seat of simple or rheumatic inflammation. Long before that period, however, I had seen other cases of diphtheritic paralysis, both local and general, affecting the eyes and the tongue; but I had seen them with- out being able to explain their nature, without having laid hold of the re- lation of the disturbed innervation to the disease in which they originated. Thus, in 1833, a remarkable case came under my observation when I was doing temporary duty in these wards for Recamier. The facts of the case were carefully reported by my lamented friend Dr. Thirial. The patient was a young woman, twenty-two years of age, who was ad- mitted as a patient into the Hotel-Dieu on the 13th June. The superior and inferior extremities were both completely paralyzed. With the right arm, she could hardly perform slight extension movements: the fingers were retracted, flexed in the palm of the hand, and when an attempt was made to extend them, pain was excited. The paralysis of the left arm was neither so generally diffused, nor in any part so complete. The patient was wholly unable to move the right inferior extremity; and she was nearly as much paralyzed in the left, with this exception, that she could push it out and slightly draw it back, in consequence of power remaining in the muscles of the pelvis. There was a certain amount of difficulty in voiding the urine and faeces. Notwithstanding the almost total loss of the general motor power of both sides of the body, sensation remained intact in the paralyzed limbs. The heat of the parts was a little below the natural standard, but they were perfectly sensible to the contact of the hand, and to differences of temperature. The organs of the senses, as well as the mental faculties, were not im- paired in the slightest degree. Speech was free: my questions were an- swered with remarkable correctness and precision. The pulse was natural. There was not much appetite, but digestion was good. This young woman was an inhabitant of a village in the department of Haute-Marne, whence she had come to Paris for treatment. She stated that she had been confined on the 14th February, consequently four months before she was received into the Hotel-Dieu. Parturition was perfectly propitious; but about fifteen days after delivery, she was seized with sore throat possessing the character of pseudo-membranous sore throat, from which she was very ill, and in great danger. The village doctor under whose care she had been, had first taken blood from the feet, then applied (on different occasions) sixty leeches, and afterwards blistered the calves of the legs : he did not however employ any topical treatment. The patient stated that the surfaces to which the blisters had been applied became cov- ered with false membrane: this statement, as Thirial has remarked, put beyond doubt the nature of the sore throat-its serious and contagious character. Notwithstanding the insufficiency, let me add, in spite of the absurdity of this treatment, the patient had the good fortune to get better; but it was not till after the lapse of a considerable time that convalescence began. Indeed, she stated that she had not commenced getting up till about the 10th April, that is to say, not till more than six weeks from the begin- ning of the diphtheritic attack. The first time that she tried to stand or walk, she observed a certain awkwardness in the movements of the right leg: she could not maintain the erect position, nor make a few steps without the aid of a staff. The 388 PARALYSIS IN DIPHTHERIA. physician to whom she complained of these symptoms, paid little attention to them, ascribing them to debility, the natural consequence of so long an illness. It is probable that a similar error has in times past been often committed, and that to a certain extent the commission of this error explains the silence observed in reference to paralysis in diphtheria. Our patient, some days after making her complaints, began to suffer from very disagreeable formication in the weak leg, and to experience considerable and increasing difficulty in moving it. In a word, at the end of a fort- night, there was complete paralysis of the right inferior extremity ; and the left arm became afterwards similarly affected. After some time, the for- mication was felt over the whole of the left side of the body: and soon afterwards, the motor power began to diminish simultaneously in the upper and lower extremity. About the end of May, the patient ceased to be able to stand, even with the assistance of a support, and was thenceforth obliged to keep her bed. After remaining in this condition for a fortnight, the patient's family resolved to send her to Paris for treatment. Thus it was that she came into the Hotel-Dieu in the condition which I have just described to you. This, gentlemen, was assuredly a case exceedingly well characterized, and seems to be one which in the present day nobody ought to have mis- taken. Nevertheless, notwithstanding the various hypotheses successively suggested by the numerous physicians following the clinic, both as to the nature and seat of the disease, the true diagnosis of this woman's case escaped me during the whole time she was under my treatment in hospital, which was two complete months. At the end of that period, being three months after the setting in of the paralytic symptoms, the recovery was perfect. No one, I repeat, seized the relation between this woman's paral- ysis and her antecedent diphtheria, during the time she was in our wards. As for myself, I never should have got at the correct diagnosis, had I not at a later period met with similar cases. In 1846, my honorable colleague, Dr. Vosseur, summoned me to see with him the female child of a joiner living in the Impasse des Feuillantines, Rue Saint-Jacques. The child had paralysis of the veil of the palate; she also had strabismus ; and a leg and arm were paralyzed. At first, I sup- posed that it was a case of hemiplegia depending upon a tubercular lesion of the brain. In a fortnight, the child died : before death, the paralysis had extended to the whole body. These cases, however, were, like the first, a dead letter to me. Yet I was acquainted with the case described by Dr. Herpin of Tours. Breton- neau narrated it to me, and said that it was a case of diphtheritic paral- ysis. The statement seemed to me incredible. I refused to see anything more in the case than a coincidence; and when, in 1851, Dr. Lasegue and I published our wTork on paralysis of the veil of the palate, I was quite satisfied with the explanation which I there gave of that affection : 1 did not perceive that in its nature paralysis of the veil of the palate was simi- lar to paralysis of the limbs, sight, &c. It was not till about the year 1852, that, enlightened by new cases, better studied and better interpreted, I understood diphtheritic paralysis as Bretonneau understood it. From that time, whenever an opportunity occurred, I, in my turn, called the attention of my colleagues to this important subject; and in this place, since 1855, I have pointed out to you cases of this kind. These cases I shall to-day recall to your recollection. In 1852, I saw, along with my colleagues Drs. Beylard, Olliffe, and Bigelow, an American young lady who had frightful diphtheria, which invaded the pharynx, nasal fossae, and internal surface of the eyelids. For PARALYSIS IN DIPHTHERIA. 389 three weeks, the patient's life was in the balance. She recovered : but during the course of her illness, she fell into an extraordinary state of adynamia. Before her attack, she was in blooming health, and had a remarkably fresh complexion ; but, from the third day of her membran- ous sore throat, she became as pale as the palest of chlorotic women, and in addition to this deprivation of color, the skin presented a bloated appearance. Being at that time ignorant of the connection of albumin- uria with diphtheria, I did not examine the urine. Notwithstanding, I repeat, the severity of the symptoms, the patient recovered; that is to say, the pseudo-membranous affections completely disappeared ; but we soon had other very formidable morbid symptoms to contend against. We first had paralysis of the veil of the palate and of the pharynx, which consti- tuted an almost complete obstacle to deglutition: whenever the girl tried to take any kind of liquid, it was at once returned by the nose. For some time it was necessary to give aliment only in the solid form, and nourish her with chocolate prepared with water, and meat broth. At the same time, it was necessary to plug the nose in such a way that the column of air contained in the nasal fossae, by presenting an obstacle to the return of the food, should perform the office of the veil of the palate. This contrivance proved successful. To this paralysis of the veil of the palate, which was also characterized by a nasal tone of voice, there was added paralysis of the visual apparatus. The patient became amblyopic and ultimately amaurotic. The arms be- came affected ; and along with loss of motor power, there was loss of sen- sation. Subsequently, the inferior extremities became paralyzed. Six weeks after recovery from the pseudo-membranous affection, the paralysis was so general that the patient was unable to stir, and so was compelled to remain in bed. Four months elapsed before she could walk in her room supported by two persons, or carry the spoon to her mouth and take her food without assistance. It required a year to complete her recovery. She is now in perfect health. I related the particulars of this case to my friend Dr. Blache, as wrell as to several of my hospital colleagues : it recalled to their recollection some other cases of a similar nature which till then had not arrested their atten- tion. Some time afterwards, Dr. Faure called me in to consult with him in the case of a child, a girl between four and five years of age, who was recovering from a diphtheritic affection. She had paraplegia of the same description as that of my young American lady, with this difference, that there was a sort of alternation in the paralytic symptoms : for example, an arm would be affected now, and by and by a leg. At the same time that Dr. Faure consulted me in this case, he published an accouut of it in the " Union Medicale." This case dates back for about five or six years. The recovery was very rapid. In 1858, I was asked by Dr. Arnal to meet him in consultation on the case of an exchange agent. Dr. Arnal informed me that his patient, after having been attacked with paralysis of the veil of the palate, experienced considerable feebleness of vision, then paraplegia, paralysis of the upper extremities : the muscles of the neck became unable to support the head in its natural position ; and finally, there was anaphrodisia. In listening to the patient's replies to my questions regarding his case, I observed a nasal tone of voice, and an aggregate of paralytic affections which led me to think that the symptoms depended on antecedent diphtheria. This was the truth. Nowadays, that is to say, since the publication of Bretonneau's paper in the " Archives," diphtheritic paralysis has been, so to speak, the order of 390 PARALYSIS IN DIPHTHERIA. the day, and has been discussed in several inaugural theses ; particularly in 1858, in his thesis by Dr. Perate, and, in 1859, by Dr. Pery, who spe- cially devoted his inaugural dissertation to the subject. However, the most extended work which has yet been devoted to diphtheritic paralysis is that which Dr. Maingault presented to the Medical Society of the Hospi- tals. The author has collected above fifty cases, six of which were seen by himself; and upon this collection of cases is based the treatise which he has recently published.* For some time past, numerous cases of this kind have occurred in the hospitals, particularly in the Children's Hospital, as well as in Parisian private practice, and at various places in France. The existence of the affection has been pointed out in the reports made on the epidemics of pseudo-membranous sore throat which have prevailed in the departments. Within the last few months, I have shown you several examples in our wards : and Dr. E. Moynier has given an account of some The great number of cases now observed, no doubt arises from cases not being allowed to pass unnoticed, in consequence of the zealous manner in which attention has been drawn to the affection; but they have also really been more common of late, a circumstance which is perhaps explained by diphtheria in recent years having assumed a peculiar physiognomy which it did not formerly possess, and which is characteristic of the toxic form of the disease. Be that as it may, there is not now a physician who has not heard of diphtheritic paralysis. Let me endeavor to give you a sketch of the principal features of the affection. There are two distinct forms of diphtheritic paralysis, one of which is severe and the other mild. In the severe form, which, thank God, is very rare, the patients sink under adynamic and ataxic symptoms: in the mild form, generally speaking, recovery takes place, and in the exceptional cases in which death occurs, it is the result of an accident, depending it is true upon paralysis, but proving mortal from a mechanical cause, the patient, for instance, dying from the alimentary bolus having got impacted in the bronchus, as occurred in a case lately described by my friend and colleague, Dr. Tardieu. In its mild form, diphtheritic paralysis has characteristics which I shall now point out. Sometimes, paralysis of the veil of the palate supervenes towards the close of an attack of pseudo-membranous sore throat, before the complete' re- covery of the patient, as happened in the case of our female patient of bed No. 9, St. Bernard's Ward ; but, generally, the period of its occurrence is after the disappearance of the false membrane, a week or a fortnight, or even a month after apparent recovery from a pharyngeal diphtheria. It declares itself by a nasal tone of the voice, such as might be attributed to destruction or great swelling of the palatine veil. The patient to whom I have referred spoke slowly, and articulated with difficulty. There was at the same time some dysphagia: fluids, which were swallowed with much more difficulty than solids, were in part rejected by the nose. When, how- ever, the paralysis affects not only the veil of the palate, but also the muscles of the pharynx, there is greater difficulty in swallowing, and the passage of the alimentary bolus is difficult in proportion to the smallness of its volume ; sometimes it gets into the air-passages, where it produces conse- * Maingault : De la Paralysis Diphtherique, Recherches Cliniques sur les Causes, la Nature, et le Traiteinent de Cette Affection. Paris, 1860. j- Moynier : Compte Rendu publie par la "Gazette des Hopitaux," numeros des 15, 22 novembre et ler decembre, 1859. PARALYSIS IN DIPHTHERIA. 391 quences which I have just referred to, and to which I shall have to return. A peculiarity observed in this class of patients by Dr. Maingault, and noticed in a work which he published anterior to the appearance of that which I have just spoken,* and pointed out also by Dr. Duchenne of Boulogne-is that they can neither blow out a lighted candle, inflate the cheeks, suck, nor gargle. To explain, gentlemen, the mechanism of the dif- ficulty of swallowing, and of the different phenomena which I am going to point out to you, would carry me beyond the limits of a clinical lecture: this mechanism has been fully discussed by Dr. Maingault in his thesis. Upon examining the pharynx of the patient, the veil of the palate is seen to be hanging down, in such away as to half-close the posterior cavity of the mouth : in place of rising and falling as usual with a frequent oscil- latory movement when the tongue is held down by a spoon, it remains almost immovable. It does not contract when an attempt is made to excite it by the point of a bistoury or pen : its sensibility, naturally so exquisite that its slightest titillation produces nausea, is completely blunted : it may, without causing any suffering, be pricked, or cauterized with hydrochloric acid or nitrate of silver. The palatine veil is generally the first part affected with diphtheritic paralysis: this might be anticipated, for in addition to the general cause, there is in operation the local condition-the inflammation of which the pharynx, tonsils, uvula, and veil of the palate are the seat-which has an influence in producing the local paralysis. It is, indeed, a recognized fact, as I have already said, that inflammation, when it invades a muscle, carries with it such a modification of the vital properties of that muscle, as to diminish or even destroy its contractility. Taking this fact alone into account, the explanation which I gave, in 1851, of paralysis of the veil of the palate was admissible; but at that time I had only looked at one side of the question, and later observations showed me that the inflammation plays but a subordinate part, though undoubtedly it has a great predis- posing influence in bringing the muscular structure under the operation of the general cause which produces diphtheritic paralysis in other parts of the body. So well sometimes, and by no means rarely, is the principal part performed by this general cause, that the paralysis of the veil of the palate does not supervene till long after recovery from the sore throat, at a time, therefore, when the inflammation being completely at an end, could no longer be an agent. Not only is the veil of the palate generally the part which is first affected by diphtheritic paralysis, but it is also a part to which I have often seen the paralysis limited. Sometimes the paralysis sets in all at once and in a general manner, attacking simultaneously, for instance, the veil of the palate, the limbs, and different organs; or perhaps the paralysis of the veil of the palate has only preceded by a few days the affections which we are now about to study ; or finally, but this is a much less usual occurrence, the paralysis of the veil of the palate may have almost entirely passed away, when other parts become paralyzed. A circumstance which clearly shows that diphtheritic paralysis depends on a general cause, and that paralysis of the veil of the palate cannot be entirely explained by the plastic inflammation of which the veil was the seat, is, that paralysis may strike the palatine veil consecutively to cutane- ous diphtheria, as well as consecutively to pseudo-membranous sore throat, as has been seen by my friends and colleagues Dr. Barthez and Dr. N. Gue- * Maingault: Sur la Paralysie du Voile du Palais a la suite d'Angine. [Thbse de Paris, 1854.] 392 PARALYSIS IN DIPHTHERIA. neau de Mussy, as also by myself in a recent case. This is a point of the greatest importance, for it demonstrates both the special character of the symptoms and the specificity of the nature of diphtheritic paralysis. The case to which I refer occurred in a gentleman sent to me from Laval by my honorable colleague, Dr. Garreau. During last February this patient took diphtheria, which was then epidemic in Laval. Two members of his family, a child and a servant, had taken the disease: in him the seat of the pellicular affection was a surface on the front of the chest, to which a blis- ter had been applied for the relief of angina pectoris, from which he suffered much. Four or five days after the application the vesicated surface ulcer- ated, and became covered with false membrane: the sore, which was ex- ceedingly painful, took five weeks to cicatrize. During the month which followed there was no sign of constitutional disturbance, the general health seemed unexceptionable, and the patient was getting ready to start for Croisic, when the symptoms supervened which led to my being consulted. Without any discoverable cause he began to experience slight difficulty in walking, and some diminution of the muscular power of the arms. He had also difficulty in swallowing, and complained of constantly having a sensation in the throat of the presence of a bulky foreign body : food, espe- cially fluid food, was swallowed with difficulty, and excited violent parox- ysms of coughing. The sensibility of the skin was blunted, and there was formication in the feet, legs, and hands. The patient did not feel his toes come in contact with the sole of his shoe: he could scarcely hold his hat, put in a button, or carry a spoon to his mouth, indeed, the mouth went to the spoon rather than the spoon to the mouth. Micturition and defecation were performed under the influence of the will, but the patient had almost no consciousness of the passage of the excrementitious matters. He had also dimness of vision, a considerable amount of amblyopia, which had sen- sibly diminished when I saw him in June. The paralytic symptoms had then, however, rather increased. The urine, treated by heat and nitric acid, gave no albuminous precipitate. There was no pain in any part of the body, and the mental faculties were not impaired in any degree. The gentleman informed me that at the time he was suffering in the man- ner described, there were, to his knowledge, several persons at Laval who were similarly affected. Among other cases, he mentioned to me that of a workman, in whom the symptoms had supervened, as in his own case, after the application of a blister, and the vesicated surface becoming covered with false membrane. Gentlemen, I beg you to observe, in corroboration of what I have said as to the secondary part which the inflammation of the throat plays in the production of the paralysis of the veil of the palate, that in the case which I have just described, that form of paralysis occurred though there had been no sore throat. Generally, however, when the paralysis is consecutive to cutaneous diph- theria, it commences in the extremities. The patients complain of numbness, and of formication extending from the fingers to the continuity of the limbs. The sensation of formication is most felt when the patients make a muscular effort: it is accompanied by a feeling of cold in the feet and hands, and of weight in the limbs. Their tactile sensibility is blunted, and sometimes the anaesthesia becomes com- plete : you may pinch them and prick them without occasioning pain. This anaesthesia may extend to the entire cutaneous surface ; but, usually, anaesthesia and analgesia exist only in certain parts of the body, precisely as in hysterical paralysis. The extremities seized are generally the inferior; and in some cases the patients either cannot feel at all, or feel very imper- PARALYSIS IN DIPHTHERIA. 393 fectly that on which they tread: they tell you that it seems as if they were walking on cotton, or on a very thick woollen carpet. Some of them can- not walk without danger of falling, unless their eyes are open. This is what is observed in other kinds of paralysis. When the hands become affected the person loses the consciousness of holding anything in them, and is un- able to seize small objects, such as needles and pins. Paralysis of the nerves of sensation, I repeat, begins generally in the inferior extremities, whence it afterwards extends to other parts of the body; but cases have been no- ticed in which the superior extremities only were affected: in some alto- gether exceptional cases hyperesthesia occurs. Along with the manifestations of paralysis of the nerves of sensation, paralysis of the motor power in different degrees also shows itself. The only sign of its presence may be the weakness which the patients exhibit, particularly when they try to walk rather quickly, or to go up or down a stair. But these symptoms do not remain thus limited : the feebleness goes on increasing, walking becomes more and more difficult, and at last, to stand is an impossibility : the individuals become bedridden: the paral- ysis may ultimately so increase as to make it impossible for the patients to raise their legs. By the aid of the dynamometer, the degree of the weak- ness of the superior extremities can to a certain extent be ascertained. You have seen that vigorous subjects, who when in their ordinary health ought to produce from 50 to 55 kilogrammes of pressure on Dr. Burq's dynamometer, are unable to show more than twenty, or perhaps not more than twelve or ten. The diminution of motor power goes on, till the pa- tients are unable to extend their arms, which are in a state of constant tremor : the paralysis still increases, the power to use the hands is lost, and the individual requires to be fed by another's hand. Like the affections of the sensory nervous system, those of the motor generally begin in, and sometimes remain limited to, the inferior extremi- ties. In most cases, however, the superior extremities are attacked in their turn, and subsequently, the muscles of the trunk and neck may become affected. My friend, Dr. Faure, who was the first to point out the fact, has accurately described it. " The general carriage of the body," says he, " has greatly altered : the whole of the upper part of the trunk is thrown back : the head, on the contrary, falls down in front on the chest; all the muscular masses of the neck and back are powerless : sometimes the pa- tients are unable to raise the head when asked to do so, and if the whole body is turned backwards, the head immediately drops down like an inert mass."* The intercostal muscles and diaphragm are sometimes struck with this form of paralysis : and the great dyspnoea of our patient of No. 9 St. Bernard's Ward, which for a short time alarmed us so much, had no other cause than this. In that woman, too, whose case presented a com- plete picture of all the symptoms we are now studying, you saw the muscles of the face, lips, and tongue become affected. The appearance of persons with paralysis of the muscles of the trunk, and the embarrassed utterance which exists when the tongue and lips are implicated is similar to that of idiots; but the precision with which they reply when interrogated demonstrates the clearness of their mental faculties. Mutability of symptoms is a peculiarity which seemed to have been first pointed out in the case of the little girl of four years of age whom I saw with Dr. Faure, of whom I have just been speaking to you, a peculiarity to which I call your attention, which I have often noted, and the presence of which, in the case which is the subject of the present lecture, you have * "Union Medicate," 3d February, 1857. 394 PARALYSIS IN DIPHTHERIA. had an opportunity of observing. Thus, you will see paralysis diminish in one limb, and simultaneously increase in another. The numbness, for example, which the patient has been experiencing in one leg, will suddenly cease, and become greater in the other leg : to-day, the right hand will not give a dynamometric pressure of more than 10 or 12 kilogrammes, and to-morrow its power will have augmented, while that of the left will have diminished : then the parts which were first affected are a second time attacked, and become more affected. This strange peculiarity, this muta- bility, does not exist in paralysis dependent upon a lesion of the nervous centres appreciable at the autopsy, but is met with in other diseases, par- ticularly in hysteria : it is also seen in the paralysis consecutive to acute diseases, as has been pointed out by Dr. Gubler in a remarkable paper which was read before the Hospitals' Medical Society.* The muscles of organic life are not exempt from the influence of the disease : I have already stated that the diaphragm may be affected : the muscular coat of the intestine, particularly of the rectum, is that most fre- quently implicated. There is, as a consequence, obstinate constipation, as 1 have often seen. In one of the cases reported by Dr. Sellerier, and com- municated on the 18th September to the Medical Society of the department of the Seine, there was first retention and then incontinence of the faeces. In some cases, the palsy strikes the bladder: there is dysuria and vesical tenesmus: the individuals urinate from engorgement: when, on the contrary, the sphincter is paralyzed, there is incontinence of urine. Virile debility, amounting sometimes to complete anaphrodisia, exists in the majority of patients affected with diphtheritic paralysis, as I have ascer- tained by questioning them on the subject. Some of you will remember a young man, of whom I shall afterwards have to speak, who occupied bed No. 19 in St. Agnes's Ward: loss of virile power was one of the first symp- toms to which this patient called my attention. You can understand that in women it is difficult to ascertain the existence of anaphrodisia. The senses of smell, taste, and hearing are affected in some cases, but the affection of special sensation which is most commonly met with is dimness of vision: my colleague Dr. Blache and I have met with numerous exam- ples. On the 15th of June last, I was consulted in the case of a girl of nine years of age, who had been attended at Vichy, during an attack of pseudo-membranous sore throat, by my honorable colleague Dr. Alquie. In rather less than a fortnight after recovery from this malady, the tone of the child's voice was nasal, but the paralysis was limited to the veil of the palate; some time later, she experienced general debility, which attracted the notice of the parents from her not entering with her accustomed ardor into her usual games. She was brought into my consulting-room, when I found that the feebleness was excessive. On trying her strength by Dr. Burq's dynamometer, I scarcely obtained a pressure of 3 or 4 kilogrammes: I also ascertained that she was presbyopic. In a few days the patient's mother again called me in: the first remark she made was that her daughter could no longer see distant more distinctly than near objects, and that instead of placing the book far from her, she was now unable to read unless she held it two or three centimetres from her nose: the presbyopia had been succeeded by myopia. Presbyopia and myopia are observed then in very many of those who have paralysis as a sequel of diphtheria. The most common of these two indications of feebleness of sight is presbyopia. A child whom I sent to * Gubler: Des Paralysies dans leurs Rapports, avec les Maladies Aigues, &c. [Archives Generates de Medec'me, I860.] PARALYSIS IN DIPHTHERIA. 395 my friend Dr. Follin that he might make an examination of the eyes with the ophthalmoscope, could not read No. 10 of Jaeger, that is to say, the sub- title of the " Moniteur des Hopitaux." Feebleness of vision advances in some cases to complete blindness, which, however, ceases after a longer or shorter interval. This transient amaurosis is sometimes one of the first symptoms of diphtheritic paralysis. Upon investigating these cases of temporary disturbance of the visual apparatus, we find that there is no appreciable structural change in the choroid membrane, the retina, or the centre of the eye. This is the conclu- sion arrived at by Dr. Follin, whose great experience and talent shown in the solution of the problem now before us, is known to all of you. Dr. Follin believes that the impaired vision depends upon paralysis of certain muscles of the eye. You are aware of the part which many physiologists assign to the action of the internal muscles of the eye in accommodating the organ to different distances: if this theory, by many considered very open to objection, be accepted, paralysis of some of these muscles would oc- casion a defect in the accommodating power, and lead, according to circum- stances, either to presbyopia or myopia. Whether the internal muscles of the eye do or do not play the part thus assigned to them in producing those visual affections of diphtheritic patients of which I have been speaking, another explanation than that now stated can be given of the amaurosis and amblyopia. Recollect how common it is for albuminuria to be coincident with diphtheritic paralysis: recollect that although you do not always find albumen in the urine of diphtheritic patients with visual affections, you do find it as a rule: moreover, I need not remind you that amaurosis, ambly- opia, and presbyopia are not unusual concomitants of albuminuria. It is allowable, therefore, to believe that in some cases belonging to the class flow before us, the existence of albuminuria ought to be taken into account, and that everything must not be ascribed to paralysis of the muscles of the eye. The existence of paralysis of the muscles of the eye is nevertheless beyond question: on it depends the fall of the eyelid, and the strabismus so fre- quently met with, which when present in one eye only produces double vision. All the affections of which I have been speaking-paralysis of the veil of the palate, of the extremities, of the muscles of the trunk and face, as well as the impaired vision-continue for a certain time, but at last com- pletely cease. Death, however, as I have been careful to tell you, even when the diphtheritic palsy has assumed the mild form, may result from intercurrent complications. I have already alluded to the case observed by my friend Dr. Tardieu, my colleague at the Lariboisiere Hospital, and published by his pupil M. Rocher in the "Union Medicale" for 1st October, 1859. In that case, death arose from asphyxia following the passage into the left bronchus of the alimentary bolus. Dr. Peter mentions in his memoir a similar case in a child of eight years of age. Perhaps there is reason for astonishment that such accidents are not more common, when we see how frequently there is difficulty of degluti- tion in patients affected with diphtheritic paralysis. Our patient of St. Bernard's Ward escaped being a victim to this terrible complication; but you recollect that it was necessary for some time to take very great pre- cautions in respect of his taking food. Notwithstanding these precautions, we had on several occasions to encounter suffocative attacks from the aliments, solid and liquid, having a tendency to get into the air-passages. When diphtheritic paralysis assumes the severe form, regarding which I am now going to speak, the termination is fatal: death supervenes in the 396 PARALYSIS IN DIPHTHERIA. midst of terrible nervous symptoms, against which the resources of medi- cine are impotent. You have observed a case of this description in St. Agnes's Ward. The patient was a man of twenty-five years of age, who on admission, stated that he had been ill for four days. I found that he had pseudo-membran- ous pharyngeal sore throat, which seemed to be on the way towards recovery on the twelfth day from that on which he was admitted to the hospital. When alarmed at the persistence of albuminuria, a paralytic affection of the veil of the palate supervened. Forty-eight hours later, the inferior extremities were affected : great weakness made walking difficult: and at the same time, there were observed loss of appetite, dysphagia, and the reappearance of a white spot on the throat. Nine days later, there was a very large quantity of albumen in the urine, and the legs were oedematous. Respiration was considerably oppressed, and I detected oedema of the lungs. The debility went on increasing; and the patient died twenty days after the beginning of the paralytic symptoms, and a month after his arrival at the Hotel-Dieu. I was asked, four months ago, by Dr. Surbled of Corbeil to see a man of 52 years of age who had contracted diphtheria from one of the members of his family. After having been ill for eight days, he seemed to have recovered, when he began to have a nasal voice, and to experience some difficulty in swallowing. His inferior extremities soon became feeble : this feebleness went on increasing, and the superior extremities in their turn became similarly affected. The motor paralysis was accompanied by numbness and formication, and was followed by an affection of the breath- ing : when I saw the man, he had considerable dyspnoea. The symptoms went on increasing in severity till death took place three months from the date of the commencement of his diphtheritic sore throat. The little girl whom I saw in 1848 with Dr. Dewulf likewise died from this severe form of diphtheritic paralysis; she was carried off* by cerebral symptoms, the nature of which I misunderstood at the time of their occur- rence, for I then attributed them to a tubercular lesion of the encephalon. The following case, reported by Dr. Millard, is very remarkable. A little girl of nine years of age was admitted, on 22d March, to the Children's Hospital, Rue de Sevres. Consequent upon an attack of mem- branous sore throat, which had commenced six weeks previously, and had continued for ten days, she retained a very nasal tone of voice, and some dysphagia, particularly a difficulty in swallowing liquids, which returned by the nose. General debility made it painful for her to walk or stand, and imparted a character of uncertainty to her movements. She remarked to her mother that her sight had become so indistinct that she was no longer able to thread a needle. She was in low spirits, and had little appetite. There was neither diarrhoea nor fever ; but for eight days, she had had a little cough. On the 23d March, the alteration in the voice was verified : on causing the child to open the mouth by telling her to pronounce the exclamation -ah! it was observed that the veil of the palate remained completely immovable. It still, however, retained its sensibility, but on tickling the uvula, nausea was excited. Sight was sensibly enfeebled, and the pupils were small and contracted. Objects held out to her, she grasped slackly, and easily allowed them to escape from her grasp. Her uncertain, totter- ing step suggested the idea of incomplete paraplegia. There was no change in the general sensibility. The urine did not contain albumen. For the first two days of her residence in hospital, she was moping, with- out appetite, and without energy : afterwards, when she became accustomed PARALYSIS IN DIPHTHERIA. 397 to her new abode, she went into the garden, and regained her spirits and some strength. There was, however, no improvement in respect of the paralysis of the veil of the palate. She was put on a tonic regimen, and took daily a gramme grains] of extract of cinchona in infusion of coffee. On 28th March, she went to mass tn the morning, breakfasted with appe- tite, and received a visit from her relations: when they left her, they were enchanted with her improved condition. She went to vespers with her companions, when, at 4 o'clock, she was seized with cerebral symptoms, which at first gave rise to the belief that she had fainted: she sunk down, without cry or convulsion, the countenance at the same time becoming altered. Dr. Millard saw her at five o'clock. She was then lying on her back: the face was flushed, the skin was hot, and the pulse, 128: she com- plained of intense headache. The mental faculties were not impaired. There existed neither contractions, convulsions, nor paralysis: but there was strabismus, and a persistence of the nasal tone of voice. There was a deep sonorous cough, without any sign of pulmonary lesion appreciable by auscultation or percussion. From the previous evening, it was noted, that she had been constipated. Being in doubt as to the diagnosis, Dr. Millard ordered the hair, which was profuse, to be cut immediately, for leeches to be applied behind the ears, a purgative enema to be administered, and sinapisms to be shifted about over the surface of the lower limbs. During the evening, general convulsions supervened : the child uttered piercing cries, and passed a restless night. The leeches had bled to the extent that was desired, and the result of the enema was an abundant evacuation. At the visit next morning, the visage was pale, and the pulse, which remained at 128, was a little compressible, and less resistant than on the previous evening. The pupils were naturally dilated, and the weakness of vision and strabismus continued to be very decided. The patient com- plained of pain in the head. Intelligence remained unaffected. The breathing was oppressed and sighing, without there being any appreciable sign of pulmonary lesion. Calomel combined with scammony was pre- scribed : forty centigrammes grains] of calomel and ten grammes [nearly 155 grains] of scammony were ordered to be mixed and divided into five equal parts, one of which she was to take every hour. At four in the afternoon, the child was in the agonies of death, and in an hour expired, without having had convulsion or con torsi on, the intelligence remaining clear to the last. No organic lesion of any consequence was observed at the autopsy, except congestion at the base of the lungs, and in the left lung two tuber- cles each of the size of a filbert nut. Thus, gentlemen, the affection of the respiration, such as we observe in malignant fevers, the vomiting, the delirium, the convulsions, the ataxo- adynamic phenomena, and the general exhaustion, are the symptoms amid which persons sink under the severe form of diphtheritic paralysis, symp- toms which bear witness to the malignity of the disease by which they are stricken, and which acts upon the essential powers of life. The absence of albumen in the urine of the patient whose case I have just detailed is a circumstance possessed of some interest. I have told you that albuminuria ought to be taken into account in considering the causes which produce the disorders of the nervous system as manifested in the visual apparatus, in muscular paralysis, and convulsions, such as our patient of bed No. 9 had, or such as those of a more formidable character which occurred in the case of the little girl of Dr. Millard; yet in the latter case, there was no albuminuria to associate with the nervous phe- 398 PARALYSIS IN DIPHTHERIA. nomena. Physicians who have made this subject a matter of special inquiry, Dr. Maingault in particular, have come to the conclusion that diphtheritic paralysis may supervene in patients who have not had albu- minuria at any stage of their diphtheria, as in Dr. Millard's case, and in that of our female patient in St. Bernard's Ward. Although I have been in the habit of every day attentively examining the urine, and finding remarkable variations in the quantity of albumen which it contained, I have hardly ever perceived any coincidence between a diminution of albu- men and the variations in the paralytic symptoms. Moreover, Dr. Main- gault has justly remarked, that the nervous affections which occur in the course of Bright's disease are convulsive and comatose in their character, and bear no resemblance to those now under discussion. With the excep- tion of amaurosis, so often met with in persons having albuminuria, no one has observed paralytic manifestations in Bright's disease. Diphtheritic paralysis, then, does not depend on albuminuria ; and it is still more deserving of notice, that it bears no relation to the intensity, extent, or continuance of the characteristic local manifestations of the dis- ease. It is no doubt most commonly as a sequel to the severe form of diphtheria, to sore throat complicated with membranous coryza, to glandu- lar engorgements of evil omen, and to plastic exudations on different parts of the body, that paralysis occurs ; but on the other hand, it is by no means unusual, in the present day, for strange disorders of innervation to show themselves in persons who have had diphtheria in apparently its mildest form. Dr. Maingault has mentioned a certain number of cases of this kind-cases in which paralytic affections, more or less general, and more or less persistent, followed pellicular disease stationed on the pharynx and occupying a very limited surface : in some of the cases, it is true, the false membranes had obstinately resisted cauterization, but in the majority, they had quickly disappeared under that treatment. Perhaps I have recalled to the recollection of some of you the history of the patient who occupied bed No. 9 of St. Agnes's Ward, and who furnished us with an example of diphtheritic paralysis supervening after an exceed- ingly mild attack of pseudo-membranous sore throat. The patient was a man aged twenty-four years of age, of vigorous constitution, and by occu- pation a discharger of barges. A month before coming into our wards, he was seized, consequent upon a chill, with shivering, fever, and very acute sore throat. At first, he remained at home without any treatment, and then went to the Beaujon Hospital, where he was placed in Dr. Gubler's wards. My colleague, whose experience in a matter of this kind cannot be called in question by any one, diagnosed the case to be one of common membranous sore throat-guttural herpes. The urine, which was carefully examined, did not contain albumen. Recovery was rapid. Some days later, however, this man's voice was nasal, his deglutition was difficult; and if he drunk hurriedly, the fluid was returned through the nose. He never- theless asked permission to leave the hospital, and resume his ordinary occupations. The paralysis of the veil of the palate continued, and he complained of a constant feeling of cold. Eight days afterwards, he ex- perienced a sensation of painful numbness: on the following day, the left hand was seized, and in eight days more, the feet and hands were affected with paralysis : the progress of the disease was slow and uncertain. You recollect the condition in which we found him on his arrival at the Hbtel- Dieu, a month after the commencement of his attack of sore throat, that is, about three weeks after the appearance of the paralytic symptoms. He tottered at every step, and did not feel the ground under his feet, so that to prevent himself from falling, he was obliged to look at his feet when he PARALYSIS IN DIPHTHERIA. 399 walked. He showed by the right hand a pressure of 20 kilogrammes on Dr. Burq's dynamometer, and by the left, 21 kilogrammes: a man of his age and of ordinary strength ought to show a pressure of 55 or 60 kilo- grammes. I found that anaesthesia and analgesia existed on the entire sur- face of the body: the right side of the face was rigid : there was neither strabismus nor amblyopia: the mind was unimpaired. This individual told us that he had completely lost venereal desire and had had no erections for a month. The functions of the bladder and rectum were regularly per- formed. Digestion was not at fault. I instituted tonic treatment, and gave iron and quinine. At a later period, I prescribed syrup of the sul- phate of strychnia, and afterwards returned to the ferruginous medicines. When the patient, in accordance with his own wish, left our wards, after a residence of about two months, he had obviously regained some strength : on the evening before he went home, he produced, by the dynamometer, a pressure of between 32 and 34 kilogrammes. Here then, we had a case of sore throat presenting all the appearances of guttural herpes, which led to paralytic symptoms, absolutely similar to those which supervene as sequelae of the most severe diphtheria. But the question may be raised: was this a case of real pharyngeal herpes ? While it assumed the herpetic form, was it not under the same morbific in- fluence which, at the same epoch, led to pure diphtheritic sore throat in other cases? Upon a former occasion I told you that the manifestations of diphtheria are exceedingly variable. Comparing that which takes place in this disease with that which takes place in small-pox, which is sometimes confluent and sometimes distinct, and which occasionally exhibits only one or two pustules-when we see what takes place in scarlatina, the specific erup- tion of which may be absent-we can quite well understand that the mani- festations of diphtheria may be very different from one another, and yet the cause of the disease be the same-that while the morbific seed is the same, the produce varies with the soil in which it is sown. In illustration of this proposition, I quoted cases from Dr. Peter's work, which seem to prove the existence of this diversity of outward form in diphtheria. If the skeptical can only see in this a coincidence, it must be admitted that the coincidence is at least a very remarkable one. Looking to such cases, and to others of a similar description which I have quoted to you, we are entitled to ask, not only whether common membranous sore throats followed by paralytic affections-cases like that of our patient of bed No. 19 St. Agnes's Ward-were not really diphtheritic sore throats ; but also, whether sore throats of apparently the most simple character may not give rise to paralysis of the veil of the palate, as I lately observed in two cases ? One of the patients to whom I refer was a man of 50 years of age, and the other a young girl of 15, a patient of my friend Dr. Leon Gros. Do not these cases of apparently simple sore throat originate in the same cause as severe diphtheria, especially when they occur during diphtheritic epi- demics ? If it be so, we can quite well understand how paralytic affections may supervene after simple, just as after diphtheritic sore throats. I do not wish you, however, to believe that simple sore throats never bring in their train paralysis identical with that which occurs as a sequel to diphtheria. Facts accurately observed by able clinical physicians show that irrespective of the epidemic influence of diphtheria, simple inflamma- tory sore throats may be the starting-point of that peculiar form of general paralysis which we have been studying; but while I admit this, I wish to state most positively that though it is very common to meet with paralysis as a sequel of diphtheria, it is exceedingly rare to see it following simple sore throat, which is perhaps the most common of all acute diseases. 400 PARALYSIS IN DIPHTHERIA*. It now remains for me to endeavor to interpret the facts which I have laid before you. What is the nature of diphtheritic paralysis ? Can it be associated with any appreciable lesion of the nervous centres? Assuredly not. It would be inadmissible to suppose that upon a persistent anatom- ical lesion could depend symptoms so variable and mutable. We could not suppose it possible for such complete recovery to take place from these paralytic affections, if they depended upon softening, hemorrhage, or any other organic affection of the brain or spinal cord. Autopsies, have, be- sides, sufficiently cleared up this subject; and I have myself had opportu- nities of ascertaining after the death of the patients, that there was nothing appreciable in the state of the encephalon or spina] marrow or their enve- lopes, to explain the symptoms during life. There takes place then, in diphtheritic paralysis, something analogous to that which occurs in certain cachexi®. When we detect albuminuria in a diphtheritic patient, the first idea which suggests itself is to attribute to that condition the disturbances of innervation which we met with. I will, gentlemen, repeat to you a remark which I have just made, that on the one hand the nervous symptoms con- secutive to diphtheria, except the indistinctness of vision also experienced by persons suffering from Bright's disease, the nervo-paralytic symptoms bear no resemblance to the convulsions and coma of uraemia : on the other hand, I again repeat, that in a large proportion of the cases of diphtheritic paralysis, not the slightest trace of albumen can be detected in the urine at any stage of the disease. We must, therefore, seek elsewhere for our interpretation. Graves (in his clinical lectures) wishing to point out the relations which exist between different diseases, mentions numerous well-known facts which present a great analogy to those we are now studying. He states that an entire crew after eating of a species of conger-eel, were seized with nervous symptoms similar to those induced by lead poisoning. Some men died in a state of violent delirium: those who survived were affected with general paralysis. In some cases the affection was permanent: in others, recovery took place at the end of three or four months. Three or four months ! mark well the duration, for it is absolutely the same as that ofVliphtheritic paralysis. Werloff, and Foster speak of paralytic affections following maladies caused by eating some other kinds offish. Cases similar in their nature to these now mentioned are not rare in pathology. When lecturing upon urticaria, I stated that paralytic affec- tions sometimes supervene in persons attacked by febris urticata.* They are observed still more frequently as sequel® of other diseases. In syphilis, irrespective of paralysis depending upon specific tumors of the encephalon and spinal cord, and osseous growths of the cranium and vertebral canal, there occur other paralytic affections which cannot be traced to any appre- ciable lesion. The correctness of this statement is proved by the case of a man who is now lying in bed No. 22 of St. Agnes's Ward. This individ- ual, who is suffering from constitutional syphilis of old standing, complains of numbness, formication, weakness, and a feeling of excessive cold in the right leg, to which these symptoms are confined : there is nothing abnormal in the state of the arm, face, or any part of the right side, except the leg. But it is still more usual for these paralytic affections to occur as sequel® of severe fevers. You remember, gentlemen, a woman who lay in bed No. 29 of St. Bernard's Ward, who, two years ago, became paraplegic consequent upon an attack of small-pox. Such occurrences are frequent after that * See p. 217 of this volume. PARALYSIS IN DIPHTHERIA. 401 exanthematous fever. The rachialgia which announces the beginning of the attack, as well as the paralysis of the inferior extremities, and the retention of urine which accompany the lumbar pains, are, as I formerly argued, phenomena of this same class. The paralytic symptoms which manifest themselves after the termination of the eruptive fever are likewise referable to a similar cause. Some of you, gentlemen, I doubt not, still recollect the two patients of St. Bernard's Ward who, consequent on typhoid fever, were struck with paraplegia. In one of my lectures on dothinenteria I called your attention to paralytic cases of this description, when speaking of the disorders of the nervous system which may impede the progress of convalescence from that fever. I stated to you that these paralytic affections, which sometimes become general, involving the nerves of motion and sensation, attack the organs of seeing and hearing-the patients being blind and deaf-and also localize themselves in the inferior extremities, the bladder, and rectum. There is a remarkable similarity between such complications of dothinen- teria and those observed in diphtheria: the similarity is all the more strik- ing from the circumstance that the paralysis consequent on dothinenteria sometimes affects the veil of the palate. Paralytic seizures also supervene during the course of, and after recovery from, typhus and cholera ; and, in a word, in connection with diseases which lead to serious disturbance of the organism and greatly shatter the nervous system. Clinical experience shows us that we can only regard as secondary causes of these seizures the prolonged suffering of the patient, the state of debility and anaemia into which he has fallen, whether as the result of the fever itself,- or of exhaustion from hemorrhages and profuse fluxes, or from having been condemned to a rigorously low diet; and that they must be looked upon as direct consequences of a morbific cause. They arise from an organic and functional modification imparted to the entire nervous sys- tem by this morbific cause, which, having acted primarily and directly, acts during the whole continuance, and even after the cessation of the malady. Here then, gentlemen, we have to do with poisons as in the cases cited by Graves: we have also to do with contagion-germs which produce symp- toms analogous to, but not identical with those we observe in diphtheritic paralysis. Similar effects follow the taking of mineral poisons. When I come to lecture on specificity, I shall remind you that poisoning with lead also produces disturbing effects on the innervation, and that among them paralysis occupies an important place: I shall describe to you the symptoms experienced by persons employed in manufactories of vulcanized caoutchouc: I shall speak to you of the effects of inhaling sulphuret.of carbon, and among the symptoms produced by that substance, which have been so admirably described by Dr. A. Delpech (the first to make them known to us), I shall call your attention to diminution of muscular power, partial paraplegia, dimness of sight, and dulness of hearing-in a word, to various forms of paralysis.* Well, then, diphtheritic paralysis belongs to the same category: its real cause is poisoning of the system by the morbific principle which generates the malady on which the paralysis depends: it originates in disturbance of the nervous system, in the modality to which it is subjected, a modality with which we are at present unacquainted, and with the nature of which we shall always, perhaps, remain in ignorance. * Delpech : Memoire sur les Accidents que developpe chez les Ouvriers en Caou- chouc 1'Inhalation du Sulfure de Carbone en Vapeur. Paris, 1856. Nouvelles Kecherches sur 1'Intoxication Speciale que determine le Sulfure de Car- bone. \Annales d' Hygibne. Paris, 1863.] vol. i.-26 402 TREATMENT OF DIPHTHERIA ASlD CROUP. It would be difficult to formulate the treatment of diphtheritic paralysis. In general terms I may say that tonic, strengthening remedies are every- thing. You therefore see me prescribe cinchona in all its forms, also vari- ous bitters and ferruginous medicines : you see me insist on the necessity of a substantial and restorative diet. According to the case I have to treat, I stimulate the functions of the skin by using aromatic lotions, dry frictions, or sulphurous baths. When the symptoms are on the wane, preparations of nux vomica have seemed to me to be of real service, by supplying, at the proper time, an excitant of muscular contractility. Sea-water baths are also indicated as a means of inducing perfect convalescence; and I believe that a well-regulated application of hydropathy might prove exceedingly useful for the same purpose. Treatment of Diphtheria and Croup. The Antiphlogistic Treatment ought to be absolutely rejected. - Alterative Treatment: Mercurials useful as Topical Agents: their inconveniences: alkalies, particularly bicarbonate of soda, of very doubtful benefit.- Chlo- rate of Potash useful in cases of average severity.-Emetic Treatment: its Inconveniences greater than its Advantages.-Serious Consequences pro- duced by Blisters.- Topical Method of Treatment by Astringents and Caustics is Best Treatment of Diphtheritic Affections.- Catheterism of the Larynx.-Indispensable Necessity of sustaining the vital powers of the patients by Food and Tonic Medicines. Gentlemen : When it became universally admitted by physicians, that pellicular affections were of the nature of inflammation, when croup was regarded as the result of inflammation of the mucous membrane of the larynx, it seemed, at the first view of the matter, to be both rational and easy, to extinguish in its site that inflammation, in general of very limited extent. Certainly, if we only take into account the local lesion, a diph- theritic patch on the skin, even though it cover the surface to which a large blister has been applied, is apparently of trifling importance: when we examine the throat of a person attacked by pseudo-membranous disease, we find that the swelling of the tonsils is very moderate, and the plastic exudation at first very limited in extent. No doubt, it might be supposed that a local disease so circumscribed, and giving rise, in the first instance, to so insignificant an amount of febrile reaction would readily yield to a pretty energetic antiphlogistic treatment, as other less extensive and less intense inflammations do not resist such measures. Local bleeding by leeches and cupping, as well as general bleeding, seem therefore to be indicated as the appropriate means to be employed for the purpose of promptly subduing inflammations which set in with so peaceful an aspect. Here, theory has been found to be at fault, as it very often is when applied to practice. It cannot be doubted, gentlemen, that cuta- neous diphtheria, pseudo-membranous sore throat, and croup, are inflam- mations:: in common with all others, I accept that proposition as the truth: but I do not think that a dominating influence-the specific character of the inflammation-has been sufficiently taken into account. I shall tell you when I come to speak of the very important question of specificity that septic maladies are personal maladies, over which the treatment which may be called physiological has generally little effect. The progress of the majority of this class of cases is unpropitious. When once the small-pox pustule is developed, whatever may be the degree of intensity in the accom- TREATMENT OF DIPHTHERIA AND CROUP. 403 panying inflammation, all the antiphlogistic resources of medicine will prove incapable of preventing it from running through its appointed stages: to arrest its progress, the pustule must be otherwise destroyed. To take an illustration from an affection which presents a striking analogy to that we are now studying: when the malignant pustule is once developed, gen- eral bleeding, depletion by leeches or cupping, however often repeated, and however much blood is taken, have no effect in stopping its progress: on the contrary, they may do a great deal of mischief to the patient. So it is in diphtheria. By the admission even of those who, taking a middle view, consider that in some cases antiphlogistic measures are useful, they never cure the disease. In my opinion, this modified belief of some physicians in the utility of antiphlogistic treatment is very open to be called in question. Nay, let me at once add, that a long experience has shown me that it is not only useless, but essentially injurious in septic diseases, which have an inherent tendency to produce prostration. The remarks which I have made on the antiphlogistic, are equally appli- cable to the alterative treatment, which is in fact its adjunct. Mercury and its preparations occupy the first place among alterative medicines. Mercurials, as you are aware, are regarded as the most powerful anti- phlogistics in the materia medica, and they are perhaps even more potent in that respect than bloodletting. You have seen, a hundred times, the effects which we have obtained from them in inflammations of serous mem- branes : you are aware that in these affections, so very formidable from their extent, seat, and concomitant fever, their beneficial influence has been lauded. Well! mercurial preparations-calomel given internally, and cutaneous frictions with Neapolitan ointment*-have been tried in Eng- land, Germany, America, and France, as antiphlogistic remedies in the treatment of diphtheritic affections, pseudo-membranous sore throat, and croup. The results, I must say, have often been successful. Without any other treatment, calomel administered at short Intervals, in fractional doses, according to Dr. Law's plan, has cured a certain number of cases. This announcement, gentlemen, may seem a contradiction to my propo- sition in reference to the dangers of antiphlogistic treatment: and here it is that the question becomes very complex. In point of fact, calomel and the other mercurial preparations involve an argument which tells in two ways. Mercury has two modes of action: it has a general action on the economy, in which case it is an alterative medicine, an antiphlogistic: it has also an exclusively topical action. When you prescribe lotions for the skin of eau phagedenique (a solution of corrosive sublimate), when you irri- gate the eye with mercurial collyria, when you apply to the eyelids red precipitate and protochloruret of mercury in the dry state or mixed with lard, when you fumigate with the red sulphuret of mercury, when you do any of these things, you institute a treatment essentially local; and it is only in an indirect manner that general results are obtained. The treat- ment which you employ is substitutive. It is only after the lapse of some time, and by perseverance in the treatment, that the mercury acts on the blood, and modifies its composition in the manner of alterative medicines. As a topical application, protochloride of mercury has seemed to me to be of real service in diphtheritic affections. When applied to the sores which are the seat of the pseudo-membranous exudations, it modifies their char- * The "onguent Napolitain," called also " onguent mercuriel double," is made by mixing with washed prepared lard an equal weight of pure mercury; and then triturating them together till the latter is killed, or in other words till the metal is so minutely divided that no globules can be seen.-Translator. 404 TREATMENT OF DIPHTHERIA AND CROUP. acter in a beneficial manner; and if it has done good in pseudo-membranous sore throat, it is by its local action. When given to a patient with pha- ryngeal diphtheria in fractional doses-say 5 centigrammes [five-sevenths of a grain] mixed with 5 grammes of sugar [77| grains], and divided into 20 packets, of which one is taken every hour-it mingles with the saliva, and in this state traverses the pharynx, touching the morbid surfaces, and modifying them in the same way that it modifies diphtheritic sores on the skin. I do not, however, dispute that this medicine may have a general action, for I know that it produces decided effects when absorbed in its passage through the alimentary canal: it modifies the blood, augmenting its fluidity, and so changing its state, that the secretions becomes less plastic. So far, indeed, am I from denying the constitutional action of this medi- cine, that I have a great dread of it; and I believe that the topical action is that alone which is of use. When the treatment is restricted to frequent mercurial frictions, a special dyscrasia of the blood is speedily produced, phenomena depending on that dyscrasia occur, salivation is induced; but, nevertheless, the diphtheria is not cured. It is not necessary to say more to show you that the mercurial treatment has its dangers from its constitu- tional effects. From its effects varying with the peculiarities of individuals, there is a risk of their passing the limits within which it is wished to restrain them; and in these circumstances the inconveniences of the antiphlogistic treatment are likely to be discovered, for if it do not at once aggravate the disease, it may prolong convalescence by increasing the debility into which the patient has been thrown by the disease. I have now to speak to you of other alterative medicines. Some years ago, Dr. Marchal, of Calvi, published several cases, which seemed to prove that the bicarbonate of soda was useful in the treatment of diphtheria. He thus restored the reputation of the alkaline treatment, which, lauded for a time, had soon fallen into discredit. Both the external and internal use of the subcarbonate of ammonia had been lauded by Rechou, but never- theless this medicine, so difficult and sometimes so dangerous to employ, had been abandoned. Chamerlat prescribed' gargles of hydrochlorate of ammonia, and Mouremans has reported a case of pseudo-membranous laryn- gitis cured by bicarbonate of soda.* The alkaline treatment had become almost completely neglected, when Dr. Marchal restored it to credit. Other practitioners in their turn came forward to proclaim successes which they had obtained with it, some of which were real though purely accidental, while others were doubtful, or very open to be called in question. In this way, general attention was directed to the treatment of diphtheria by bicar- bonate of soda, and by and by, enthusiasm mingling in the discussion, it was soon believed by some that in this medicine had been discovered a specific for diphtheria, and even for croup. Calm reflection, however, explained the marvellous results which were announced, and reduced them to their real value. In fact, it was easy to see that in the cases in which the alka- lies were said to have cured pseudo-membranous affections, the cases were of that kind from which spontaneous recovery is usual, such as scarlatino- membranous affections, and such accidental membranous affections as occur during chronic diseases. This is of itself sufficient to deprive the facts of their value. There is always something seductive in a theory: I myself put forth one when I wrote that there was ground for hoping that some ad- vantage might be derived from the alterative and antiplastic action of bi- carbonate of soda in modifying the general diathesis which seems to preside * Encyclopedic des Sciences pour 1'annee 1839. TREATMENT OF DIPHTHERIA AND CROUP. 405 over the development of diphtheritic affections.* The general action of alkalies, the peculiar state of the blood which they produce, is an undoubted fact demonstrated by our predecessors-by Cullen among others; but this alkaline cachexy (for so it has been called) is not produced till the use of the alkalies has been long continued, and however protracted the duration of the diphtheritic attack, it never lasts long enough for the antiplastic influence of the alkaline treatment to come into operation. This treatment, far from producing the benefits which have been attributed to it, is the source of serious evils: it is open to the same objections as the alterative treatment, the dangers of which I have just been pointing out. The topical influence,'however, of the bicarbonate of soda remains to be noticed: it has been thought that its solvent action assists in softening and detaching the false membrane. I was formerly a believer in this topical influence, and there are physicians who have still this faith, which additional experience has taught me to relinquish: the modifications induced in the diphtheritic secretions by alkaline solutions are far from being such as they seemed «to me when first I made them the subject of observation. Chlorate of potash, gentlemen, is another medicine which has recently attracted much attention. This salt, discovered, as you are aware, by Berthollet, at the end of last century, entered the domain of therapeutics about the year 1796. In 1819, Chaussier proposed it as a remedy in croup. It had completely fallen into oblivion, when Dr. Blache, repeating the ex- periments made in 1847 by Hunt and West with this medicine in the treat- ment of gangrene of the mouth and pseudo-membranous stomatitis, was led to try it in the treatment of pseudo-membranous sore throat and croup. Dr. Isambert, when interne of Dr. Blache, studied with care and intelli- gence the numerous trials made with this medicine at the Children's Hos- pital, and made them the subject of his inaugural thesis.f The first results obtained in the treatment of membranous sore throat, though less satisfac- tory than in the treatment of ulcero-membranous stomatitis, were, never- theless, encouraging. The chlorate of potash, no doubt attained a vogue far beyond its merits, but the cases accumulated from all quarters justified its being regarded as capable of rendering some service in diphtheritic sore throat, though not entitling it to be looked on as a very efficacious remedy. With Dr. Isambert, I admit that the beneficial results obtained in cases of average severity are shown not only by real and ultimate success, but also by an action upon the mucous membrane of the pharynx, altogether special and in a certain sense elective, an action analogous to that which is ob- served in pseudo-membranous stomatitis ; but I deny that it does any good in cases of severer type. When such cases have been treated solely by it, I have always observed failure; but when employed conjointly with other measures, its operation has appeared to me to be beneficial, though I can- not make an absolute affirmation to that effect. This remark applies to pseudo-membranous sore throat, but is still more applicable to pseudo- membranous laryngitis. No doubt, from time to time recoveries occur in cases of croup treated by chlorate of potash ; but these cases are in no respect conclusive, as its use in them has generally been combined with other measures, particularly with emetics, to which solely the cure may sometimes be ascribed. As, however, this drug is supposed to have a gen- eral influence on the system, and to prevent plastic exudation, and as its employment does not induce bad consequences like those caused by alkalies * Trousseau et Pidoux : Traite de Therapeutique. f Isambert: Etudes Chimiques, Physiologiques, et Cliniques, sur 1'Emploi Therapeutique du Chlorate de Potasse, specialement dans les Affections Diphther- itiques. Paris, 1856. 406 TREATMENT OF DIPHTHERIA AND CROUP. and mercurials, there is no reason why it should not be given in obstinate cases. You must not, however, too much rely on its virtues, and you must not employ it to the exclusion of other treatment of established efficacy within certain limits. I ought also to mention the treatment by bromide of potassium employed in doses of from 5 to 10 centigrammes; and by bromine, a medicine by the use of which Dr. Ozanam states that he has obtained the most remarkable success.* In consideration of the brilliant results announced by the in- ventor of this treatment, and also taking into account that he follows a different system of treatment from that which I pursue, and one which in- spires distrust, it is necessary to maintain a prudent reserve. As the treat- ment of pseudo-membranous affections is everywhere being experimentally investigated on a large scale, there is nothing to prevent trials being made with bromine as well as with other drugs. Bromine and its compounds are not the only substances to which a cer- tain amount of specific virtue has been attributed. You will recollect that the sulphuret of potassa was warmly recommended by Lobstein, and Pro- fessor Fritz, of Magdeburg, in cases, however, in which the diagnosis was doubtful; and it was also vaunted by Dr. Maunoir of Geneva ; and subse- quently, mention was made of it by Drs. Rilliet and Barthez. j" It is not now employed. The same may be said of polygala senega, which at one time enjoyed likewise a great reputation, but which, owing its good effects to emetic and purgative properties, must be placed along with the thera- peutic agents of that class, regarding which I have forthwith to address you. But before I proceed to do so, I wish to mention an excellent medicine, recommended by Dr. Trideau (of Andouille), a distinguished practitioner of Mayenne.J This physician, comparing diphtheritic with catarrhal affec- tions, and trusting in the latter to the good effects of balsamic medicines, had in the first instance the idea of employing copaiba, and afterwards cubebs, in a dreadful epidemic of diphtheria, raging in the department of Mayenne: by using these medicines, he obtained numerous recoveries. Copaiba has the disadvantage of disturbing the stomach, but cubebs rather increases the appetite, and ought, for that reason, to be preferred. I have had occasion to recommend the cubebs treatment, and to it I owe rather remarkable success-particularly in a case I attended with Dr. Peter of a lady whose granddaughter was treated by homoeopathy, and died of croup. The lady, who had, in addition to pharyngeal diphtheria, a commencement of pseudo-membranous coryza, recovered from all the diphtheritic symptoms in five days. The following is the treatment which I recommend. I order a packet of four grammes [62 grains] of the powder of cubebs to be taken in unleavened bread every four hours; and at the same time I direct that every half hour lemon-juice be applied to the throat by means of a camel's- hair pencil. I associate with the sort of substitutive action of the cubebs, the topical action of a vegetable acid, which is certainly not very ener- getic ; but its feebleness is compensated for by frequency of application. As a good substitute for the powdered cubebs may be used the capsules of the extract of cubebs. Each capsule contains equal to seven and a half grammes [about 108 grains] of the pepper. In children Dr. Trideau recom- * Ozanam: Memoire sur 1'Action Curative et Prophylactique du Brome contre les affections Pseudo-membraneuses. 8vo. Paris, 1859. f Rilliet et Barthez : Traite des Maladies des Enfants. j Trideau: Nouveau Traitement de 1'Angirie Couenneuse, du Croup, et des Autres Localisations de la Diphtheric. Paris, 1866. TREATMENT OF DIPHTHERIA AND CROUP. 407 mends the use of a syrup of cubebs composed of 12 grammes [186 grains] of powdered cubebs, and 240 grammes [between 5 and 6 ounces] of simple syrup. A teaspoonful of this syrup is given every two hours. On the third or fourth day of the treatment, there generally appears a scarlatinous exanthem, which usually coincides with the disappearance of the false membrane. I now come to speak of the treatment in cases of pseudo-membranous sore throat and of croup, which I call treatment by indirect agents-by emetics and revulsives. Emetics have been and are still regarded by a large number of physi- cians as among the most powerful remedies in croup. If laryngismus stridulus, or false croup, be included under that name, emetics are of un- questionable utility; and for reasons regarding which I wish to say a few words. Whatever may be the special properties of the emetic you administer, whether it be veratrum album, violet root, asarum root, or the polygala which I have just mentioned-whether it be sulphate of zinc, sulphate of copper, or tartar emetic-in addition to the vomitive action-you will get an antiphlogistic effect. If vomiting be excited by other than pharmaceu- tical means, this same result will be obtained. There will be induced nausea, that peculiar state of discomfort which precedes the rejection of the contents of the stomach. The pulse becomes small and frequent, and the heart beats very feebly: the countenance becomes exceedingly pale: the body is bathed in sweat. In a word, the patient is thrown into a state analogous to lipothymia, the duration of which may be considerable : there occurs, though in a less degree, something similar to that which follows bloodletting in some persons. You will thus perceive how it is that by a disturbance of the system affecting chiefly the nervous system, there is pro- duced a contra-stimulant impression sufficient to extinguish slight inflam- mation. Now, in false croup, the inflammatory element, under the influence of which is developed the spasmodic element leading to the fits of suffocative cough, which it is our object to subdue, this inflammatory element, I say, not in general going beyond what may be called a slight inflammation, we can conceive the utility of emetics; but the aspect of affairs is very differ- ent when we have to do with a pseudo-membranous laryngitis-we cannot then count on the contra-stimulant effect of the emetic treatment, but only on the mechanical action. Let me explain. Every one who has had to treat children in croup must have seen cases in which there was a great amelioration of the symptoms consequent upon the administration of an emetic: this change for the better, as is easily perceived, depends on the efforts of vomiting having caused expulsion of the false membranes which lined the larynx and trachea, rendering respira- tion easier, by removing the obstacle which they presented to the passage of air through the lungs. As to the dynamic action of emetics, to which some practitioners attribute the benefit which they produce, it can only exert an influence upon the inflammation in which the false membranes originate, and it is impossible to grant that it can produce any influence whatever on the exudations which have been already formed. Those who wish to see in the emetic treatment, and particularly in the employment of tartarized antimony, of which they speak in the highest terms of praise, a dynamic action, in which I do not believe, tacitly admit that that action is much less real than they say it is, and that its mechanical action is much more efficacious. In point of fact, they insist on the necessity of exciting 408 TREATMENT OF DIPHTHERIA AND CROUP. vomiting; and their statistics show that the patients have no chance of recovery, unless they have thrown off false membranes. I advise you to read the remarks of Valleix on this subject :* you will then see that he and I have come to the same conclusions in respect of this question. The action of emetics then, is mechanical: it is by clearing the air-passages of the plastic deposits, that they prove of service. The ad- vantages derived from this treatment must not, however, be exaggerated. When I resort to it in the hope of obtaining the good effects which one is entitled to expect, I am aware that these effects are transient. I know that diphtheria is a disease in which the inflammation giving rise to the false membranes will last for a limited time, that it will continue after the first secreted false membranes have been expelled, and give rise to the forma- tion of others in their place. Now, if by a repetition of the same treatment, if by causing the false membranes to be expelled as soon as formed, I pre- vent death from asphyxia, although I do not by direct means accomplish a cure of the malady, I carry out a useful treatment, inasmuch as by pro- longing the life of the patient whilst the diphtheria is running through its stages, the time may come when, that inflammation having reached its natural termination, the recovery of the patient will take place. The selection of the particular emetics to be employed is not a matter of indifference. Tartar emetic, so lauded by some, seems to me to be the most dangerous of all emetics. Dr. Millard, in his excellent thesis, has very properly insisted upon the drawbacks to its In point of fact, it often causes formidable symptoms, such as obstinate vomiting and cho- leriform diarrhoea. It causes extreme prostration, and often accelerates death. The dangers which I enumerate, experience has now sufficiently pointed out. Sulphate of copper, however, does not deserve the reproaches directed against it; and I often have recourse to it. Administered accord- ing to the method which I employ, that is to say, in minutely divided doses, it is easier to avoid producing effects in excess of those desired. But whatever utility may, under certain circumstances, attach to the emetic treatment, too much reliance must not be placed in it. After a long career of practice, after having seen a great number of persons, children and adults, suffering from diphtheritic sore throat, I can testify, that the failures have been much more numerous than the successes obtained by this treatment. Recollect that after you have administered an emetic, and obtained a decided beneficial result from it, the symptoms which have been suspended will again show themselves; often, within a very brief space of time, the oppressed breathing, and the suffocative fits from which you have relieved the patient, will return, in consequence of new false membrane having been secreted. If you should a second time be fortunate enough to cause their expulsion, the third time you employ the same measures they will prove a failure; you must, therefore, take care not to induce nausea too frequently, lest you induce such a degree of weakness as will leave the patient without sufficient strength to contend against the disease, when it has become necessary to have recourse to tracheotomy. Graves, in his " Clinical Lectures," speaks strongly in favor of the re- vulsive treatment of croup, but his statements evidently apply to cases of laryngismus stridulus: the method extolled by the eminent clinical pro- fessor of Dublin is no doubt very useful in false croup: I have already * Valleix: Guide du M&Jicin Practicien, 5me edition, revue par Lorain, t. ii, p. 111. Paris, 1866. t Millard: De la Tracheotomie dans le cas de Croup, Observations Receuillies & I'Hopital des Enfants Malades. Paris, 1858. TREATMENT OF DIPHTHERIA AND CROUP. 409 explained it to you, when lecturing on the complication of measles. I shall return to the subject when I come to speak of false croup; and I shall then tell you that there are circumstances in which blisters are useful, although they may be slower in acting than hot water, which Graves employed. But when the disease we have to treat is real croup-when we have to do with laryngeal diphtheria-blisters are not only useless, but their appli- cation is too often productive of the most serious consequences. Reflect, and without difficulty you will easily understand how absurd it is-the expression is not too harsh-to expect any advantage in diphtheria from blisters. Supposing that the larynx is coated with false membrane, the condition in which it is generally found, for no one entertains the idea of applying a cantharides plaster till extinction of voice, dyspnoea, and par- oxysmal respiration have supervened-supposing then, I say, that the false membrane is present in the larynx, it is not against the inflammatory con- dition in which plastic formations originate that we have to contend, but with a foreign body-for false membrane is really a foreign body-obstruct- ing the passage of the air through the ramifications of the respiratory pas- sages. What possible advantage can result from the use of revulsives and blisters, the action of which is essentially dynamic, against a lesion which is purely mechanical? It would be as useful to blister the neck of a child suffocated by the passage of a haricot bean into the windpipe. You would certainly call it madness in a surgeon so to act under such circumstances; and yet the surgeon so acting would not be doing anything different from the physician who hopes to cure croup by cantharadine revulsives: there is, however, this immense difference between the two, that whereas in the case of the haricot bean the treatment would be useless, it can at least do no harm, while in a case of croup the results may be most disastrous. This is a point on which it is necessary to insist. I have told you, gentlemen, when giving you the history of diphtheria, that any wound, the very smallest solution of continuity in the skin, may become the seat of new manifestations of the disease in a patient attacked with plastic sore throat. I stated that it was enough that a child should have croup or pseudo-membranous sore throat for diphtheria to be commu- nicated to other members of the family, who, up to the time of their seizure, were in perfect health, but had on some part of the body a solution of con- tinuity to afford a door of entrance to the disease. You will see in children who have been blistered on the arms for catarrhal affections, a very common practice, and which may even have been resorted to by medical practitioners -you will see the blistered surfaces become covered with false membrane, if the children are living in the midst of diphtheritic contagion. Then, as I have already pointed out to you, the plastic affection extends beyond the denuded surfaces. I cited several cases, such, for example, as that reported by Dr. Samuel Bard, in which the diphtheritic disease, commencing in a surface to which a blister had been applied, gradually spread till it covered a large space, and induced symptoms which terminated in death. If such symptoms arise, in consequence of solutions of continuity, in persons not under the influence of the diphtheritic diathesis, they are all the more to be dreaded in those in whom manifestations of that diathesis have already shown themselves. I gave you the details of the case of a young man, who, just as his recovery from croup was completed, was attacked by cutaneous diphtheria, and was carried off by it in ten days. In that case the cutane- ous affection began in a blistered surface on the front of the neck, gradually extended, and at last covered the chest with false membrane, as if with an immense breastplate. The situation of the solution of continuity matters little: whether you apply a blister to the nape of the neck, or to the front 410 TREATMENT OF DIPHTHERIA AND CROUP. of the neck or chest-wherever you have a surface denuded of epithelium- the pellicular affection may show itself, and become the cause of a compli- cation difficult to contend against. During ten, twelve, fifteen days, or even longer, you will have to combat the disease by the most energetic cauteriza- tions, and you may believe that you have mastered it, when symptoms of general poisoning of the system will appear, symptoms in short of that ma- lignant form of diphtheria under which, do what you will, your patient will sink. Death, however, in these cases, does not always take place in this way: sometimes, in consequence of the extension of the diphtheritic inflam- mation, the surfaces invaded by diphtheria, after recovery from the princi- pal disease has taken place, become the seat of very extensive suppuration, which may destroy the by an exhausting hectic fever. Gentlemen, I beseech you to adopt the rule of all true practitioners, and never, under any pretext whatever, apply a blister to a patient who has plastic sore throat or croup. When called in to cases in which they have been applied, lose no time in employing energetic topical means to modify the character of the blistered surfaces. Notwithstanding the opposition to topical treatment, at present existing, it is the pre-eminently best treatment of diphtheria: it is quite as much in- dicated in this disease as in malignant pustule: I have already insisted upon this capital point in practice. Besides red precipitate which I have sometimes employed, and the protochloride of mercury which I have already mentioned as a medicine possessing a certain power in modifying the action of surfaces invaded by pellicular disease, besides and superior to these mer- curial preparations, astringents and caustic are the agents by which the topical treatment is best carried out. From time immemorial, local treat- ment has been employed. As Bretonneau has well remarked, at the period when the disease bore the name of the Egyptian disease, there was also an ointment called Egyptian, which was pre-eminently anti-diphtheritic, viz.: a met cupratum, a mixture of verdigris and honey. Read the chapter of Aretseus entitled " De Curatione Pestilentium in Faucibus Morborum," and you will therein see that he not only recommends the application of acrid lotions-" illitiones acriorum medicamentorum faciendce sunt"-but also rec- ommends that the disease should be attacked, not by the actual cautery (the application of which he considered difficult) but with medicinal sub- stances possessed of properties similar to fire: "porro igne vitium adurere, cumin superiori parte sit: imprudentis esse proper isthmumjudico. Sed med- icamentis igni similibus quo, et depastio coerceatur, et crustce deddant, utendum prcecipio." He prescribed a mixture of alum, powdered gall-nuts, and honey ; likewise dried pomegranate flowers mixed with hydromel; and also calamine. He likewise insufflated powdered alum and gall-nuts into the throat by means of a tube. You perceive, gentlemen, that the means employed in the present day are far from constituting a new mode of treating diphtheritic sore throat. It is very remarkable that the efficacious treatment of Aretseus should so long have been forgotten. In the 17th and 18th centuries, when this form of sore throat reappeared in epidemic forms, when the suffocative malady, or Egyptian disease, made so many victims, nothing was heard of it. Bre- tonneau himself, who, when he published his treatise on diphtheria, knew better than any other person what Aretseus had written about alum, had only a partial belief in its utility, and neglected to employ it. It was not till a later period that he had any confidence in it. The following are the circumstances under which he began to place some reliance in it. I told him that during the epidemic in the departments constituting the old province of Sologne, I had had occasion to observe the efficacy of this TREATMENT OF DIPHTHERIA AND CROUP. 411 medicament. In point of fact, I knew that in the commune of Marcilly- en-Vilette where at first 66 persons died in a population of 600, this fright- ful-mortality suddenly diminished, and during the two or three following months there were very few victims. To get at the reason of this happy change, I visited the district. I there interrogated the parish priest, who was well acquainted with all that had taken place, and learned from him that the white sore throat had proved a less formidable scourge from the time that the patients had been attended by a woman who kept an inn in the locality, and who possessed a great reputation for curing diseases of the eye. The priest was ignorant of this woman's therapeutic secret. I then applied to the woman herself, but she refused to tell me, and contented her- self by sending me to two patients upon whom at the time she was in at- tendance. One of them was a young lad, a journeyman miller, 13? years old. I verified in him the presence of false membrane covering the uvula and tonsils. Some time previously, there had been three deaths in the family of this individual, who had been under treatment for five days: he showed me his gargle, which besides using as a gargle, he injected into the throat by means of a syringe. It was a solution of alum in vinegar and water. When I left the district, this young man had completely recovered. I collected several similar cases; and having discovered the secret of the landlady of the inn, I told her what it was. She then admitted that she employed alum, and stated that she had been led to use it as a remedy for the " white sore throat " because she had seen it cure aphthae of the mouth [chancre de la bouche} in swine, a disease characterized by white pellicles on the gums and throat, and consequently presenting, as this good woman did not fail to observe, a certain resemblance to diphtheria. I communicated to the prefect of the department my documents, and an account of the cases which I had observed: the mode of treatment was forthwith printed, pub- lished, and sent to the different communes. I at the same time mentioned what I bad seen to Bretonneau, who in consequence of my statements em- ployed alum : and at present it is used by all physicians in the treatment of diphtheria. Tannin is another medicament mentioned by Aretseus in the passage I quoted ; and it is one which you have seen me employ in all our cases of pseudo-membranous sore throat. Aretseus, it is true, does not mention tan- nin by name, because in his day the substance was not so known; but he speaks of powdered gall-nuts, which he prescribed to be used by insuffla- tion, and in mouth-washes. Tannin and the gall-nut are the same thing, inasmuch as the former is the active principle of the latter. Alum and tannin in insufflations, mouth-washes, and gargles are powerful topical agents, and are of great service in the treatment of diphtheritic sore throat. Let me recall to your recollection the manner in which I employ them. I follow exactly the plan of Aretseus. The alum is brought into contact with the lower part of the pharynx by insufflation through a straw, a piece of elder from which the pith has been extracted, or, if nothing else is at hand, a tube made of stiff paper. It is not necessary to be very exact as to the quantity of powder you employ, provided you employ enough : one gramme, two grammes, or more may be used. The only condition indis- pensably necessary for the proper application of the powder is that the tongue be very effectually held down during the insufflation. This detail, though apparently trivial, solicits our attention for a few minutes. It may appear an easy matter to depress a child's tongue whilst you examine the throat, yet I do not hesitate to say that few know how to perform that operation and proceed to an examination which is so much resisted by the little patients. However, by taking the precautions which I am now going 412 TREATMENT OF DIPHTHERIA AND CROUP. to point out, it is easier to examine in opposition to the will of the indi- vidual the throat of a child than the throat of an adult, for in the one case it is impossible effectually to struggle with the patient, whereas, by man- agement, in the case of the child, the end in view can be attained. First of all, you must let the child see that you are his master; and when he has seen that resistance is useless, he will cease to offer any. To accomplish this object, place him on the knees of an assistant, by whom he is to be firmly held: another person is directed to keep the head fixed in position. When the child struggles and cries, seize the opportunity of his opening his mouth to introduce the handle of a spoon, pushing it back quite to the base of the tongue. As a consequence of this proceeding, the child, being seized with a desire to vomit, opens the mouth still more widely, and you are thus enabled to see to the very bottom of the throat. If, however, you only introduce half way the handle of the spoon, he will close his teeth upon it, and you will experience the greatest difficulty in pushing it farther on. One such examination successfully conducted will often be sufficient to enable other examinations to be made whenever they are required, as it will have shown the child that he has to do with a party stronger than him- self. By proceeding in the manner now described, it will be easy to in- sufflate the alum, or to introduce a camel's-hair pencil charged with a lotion or with honey in which the alum is mixed. It does not matter, I repeat, that the quantity is in excess, because no inconvenience results from the patient swallowing a little alum. The insufflations ought to be repeated from four to ten times in the twenty-four hours: it is necessary that they should be frequent in the early period of the disease. To render the medication more powerful, the insufflations of alum ought to be alternated with insufflations of tannin. From forty to fifty centi- grammes [4|-grains] of the latter may be used. This is precisely the treatment of Aretaeus, restored to favor by Dr. Loiseau of Montmartre. I have recently, in adults, sometimes substituted for insufflations of tan- nin, the inhalation of the vapor of a strong watery solution of that sub- stance, as adults inhale easily; and I employ in this operation the " ap- pareil pulverisateur" constructed in accordance with the suggestions of Dr. Sales-Girons. You are aware, gentlemen, that that physician, struck by the fact that the vapor of a mineral water contained little or none of the saline mineral ingredients, conceived the idea of substituting for the inspi- ration of vapor, inhalations of the mineral water reduced to very fine pow- der. This is not the place to describe to you the means he adopted to ac- complish this: I will only say that the surgical instrument makers have constructed, in accordance with this principle, a portable apparatus easily employed at the bed of the patient, and which you have seen in daily use in our wards. Drs. Roger and Peter have recommended irrigation, per- formed by the irrigator in common use. They say that " irrigation per- formed several times a day is physically and therapeutically beneficial by cooling the inflamed parts, and by likewise possessing the mechanical ad- vantage of removing the false membranes, or at least assisting to detach them, and of thus cleaning the throat." It is even possible to dissolve a portion of the diphtheritic products by this process. At the Children's Hospital Dr. Roger has frequently caused the disintegration and almost complete disappearance of false membranes by placing them for five or ten minutes in a glass filled with a saturated solution of lime.* In my opinion, and in the opinion of very many others, the treatment * Roger (Henri) et Peter (Michel): Article, "Angine Diphtherique : Dic- tionnaire Encyclopedique des Sciences Medicales," t, v, p. 42. TREATMENT OF DIPHTHERIA AND CROUP. 413 of pseudo-membranous sore throat by astringents is so useful, that if we could always be sure of our instructions being properly carried out, the catheretics and caustics to which you see me have recourse would be much less frequently employed. The use of ca,theretics and caustics in diphtheria is nothing new, and they are mistaken who have supposed that it dates no farther back than Bre- tonneau : he never dreamed of appropriating to himself the credit of having originated this treatment. During last century, physicians were strongly in favor of cauterization with the spirit of salt, that is to say with hydro- chloric acid, in the treatment of those affections which they designated gangrenous sore throats. Marteau de Granvilliers was said to have obtained great success from using it during epidemics of 1759 and 1768, of which he published accounts. Van Swieten, also, in several passages of his Commentaries on the Aphorisms of Boerhaave speaks of mouth-washes containing spirits of salt. Hydrochloric add is one of the most energetic topical agents at our dis- posal for the treatment of pseudo-membranous sore throat. Pure fuming acid may be employed without hesitation, and cauterization with it may be repeated three or four times in the twenty-four hours. Hydrochloric pos- sesses the advantage over sulphuric and nitric acids of modifying the mor- bid surfaces without going any deeper into the tissue than nitrate of silver. It has, however, one drawback which I must point out to you, as it might sometimes mislead the practitioner. When a mucous membrane not cov- ered with false membrane is touched with hydrochloric acid, a white spot is immediately formed, presenting the exact appearance of a diphtheritic exudation. This plastic exudation is similar to that produced by can- tharidine and by ammonia ; and it is not always easy to distinguish the morbid product of diphtheria from that caused by the acid, so that from not knowing whether the disease is cured, the treatment may be continued after it has ceased to be required. To avoid this inconvenience, it is better, after making three or four cauterizations during the first days of the mal- ady, to suspend the use of the caustic, substituting for it insufflations of alum and tannin. At the end of a period of twenty-four or thirty-six hours, the white spots produced by the hydrochloric acid will have disap- peared, and it will be easy to see the exact condition of the parts. Nitrate of silver, introduced into general use by Bretonneau thirty years ago, is more commonly employed than hydrochloric acid. The reason of this is obvious : every practitioner has lunar caustic in his pocket-case of instruments, while he has not hydrochloric acid always at hand. But the nitrate of silver has inconveniences similar to those possessed by the spirit of salt, and it has them in a higher degree, particularly if it is used in the solid form. A small slough is formed on the part touched by the solid nitrate, a sort of white pellicle, which remains for one or two days: if the cauteri- zation be often repeated, it is very difficult to avoid the mistake which I have just brought under your notice. Although I have long been aware of the risk of committing this error, I very recently fell into it, in the case of a man with sore throat, who came from Chantilly to consult me. I found one of the sides of the uvula and one of the tonsils covered with white false membrane : on the other tonsil there was also a spot presenting a similar appearance. The patient did not mention that anything had been done for him by his medical attendant, and even asserted that he had not been the subject of any treatment. He returned home, carrying with him a letter addressed by me to my honorable colleague at Chantilly, whose attention I directed to the thick false membranes which I had seen. I certainly added that these false membranes were not of a more than 414 TREATMENT OF DIPHTHERIA AND CROUP. usually shiuing whiteness, but that as they were thick and occupied a large surface, I feared they were diphtheritic. I concluded by recommending the treatment which I thought ought to be adopted. Dr. D. in reply informed me, that the pseudo-membranous deposits were the results of cau- terizations with nitrate of silver, performed for the purpose of causing abortion of an inflammatory sore throat for which the patient had con- sulted him. When used in solution, nitrate of silver is without the drawback, which I have pointed out as belonging to the salt, in its solid form. Although the solution produces a whitish exudation it forms a superficial patch easily distinguishable from diphtheritic exudation. This remark is applicable to the strong solution I am in the habit of employing, which is in the proportion of three parts by weight of water to one of the salt. The solution has another advantage over the solid nitrate, besides that which I have now pointed out. Even when the cauterization is made with an instrument bent at the extrem- ity in such a manner as to enable the operator to carry the caustic pencil behind the veil and behind the pillars of the veil of the palate, and to reach the vicinity of the epiglottis, cauterization with the caustic pencil as arranged for the pocket-case can never be brought into contact with all the affected surface, as can be accomplished when the solution is used. By fixing a sponge saturated with the caustic solution at the extremity of a piece of bent whalebone, the operator is enabled to touch the upper part of the larynx, and the posterior cavity of the pharynx-to reach even to the Eustachian tube and posterior aperture of the nasal fossae, as is fre- quently necessary. When the disease is confined to the tonsils or other parts within view, the solid caustic or a badger's-hair pencil will be found quite sufficient; but as it is often otherwise, or at least as there is often reason to fear that the diphtheria has invaded remoter parts, cauterization with the sponge is preferable. It is important to use a piece of whalebone hav- ing a certain curve. It ought to be round, and to possess rigidity sufficient to enable it to overcome the obstacles presented by the resistance of the patient and the contractions of the pharynx. A gun or pistol cleaning- rod, failing that, an umbrella whalebone, will answer the purpose. Having rounded the whalebone, it is plunged in boiling water or exposed for some minutes to the flame of a candle, after which it is bent: it is then placed in cold water to restore its rigidity and cause it to preserve the curve imparted to it when in a warm and pliable state. Its extremity is then armed with a very small sponge secured by thread, or, better, still, by sealing-wax. To enable the cauterization to be conveniently performed, it is necessary to depress the tongue well, and firmly to retain it in that position by means of the tongue-depressor or the handle of a tin spoon bent almost at a right angle. The instrument by which the tongue is depressed must be introduced as far back as the insertion of the base of the tongue, elevating at the same time, as much as possible, the handle. These details have their value: by neglecting them, there is not only a chance of not cauterizing the affected parts, but likewise of needlessly cauterizing parts which are not implicated in the malady. But by adopting all the precau- tions upon which I have now been insisting, nothing is simpler than to operate on the pharynx and reach the superior orifice of the larynx, which latter it is always necessary to accomplish, when the patient begins to cough, and to show symptoms of diphtheritic inflammation of the glottis ; and it is equally easy to carry the cauterization back as far as the posterior orifice of the nasal fossae. The sponge ought not to be too wet, lest there- by the tongue be injured and the teeth blackened. These consequences may not be very serious; but still, an unnecessarily extensive cauterization is TREATMENT OF DIPHTHERIA AND CROUP. 415 painful, and ought, therefore, to be avoided: moreover, they are objection- able as liable to place new obstacles in the way of future necessary opera- tions, by rendering the patients, if children, still more determined against submission. Another inconvenience attending the use of nitrate of silver is its property of indelibly staining linen, when the patients spit, as they always do after the cauterization, or when they vomit, which is not an unusual occurrence. The avoidance of this staining is apparently an extra-scientific consideration, but still it is not without importance in practice. Sulphate of copper, the action of which is quite as energetic as that of the nitrate of silver, has not the same drawbacks. It causes no membran- ous patches to appear on the surfaces which it touches : you, therefore, see me employ it by preference to the nitrate, the preparation I use being a saturated solution. The actual cautery has likewise been employed by some physicians. Long ago, I saw it used ; that is to say in 1828, during the Sologne epi- demic, of which I have spoken to you. Dr. Bonsergent, an old practitioner at Romarantin, a town in Sologne, cauterized with the actual cautery the diphtheritic throats of children. The iron which he employed was the tool used by makers of wooden shoes in scoopingout the sabots; he made one of its extremities red hot, and wrapped up the other in wet tow, or placed it between two pieces of wood to serve as a handle; and thus it was that he applied the actual cautery to diphtheritic tonsils. I had an oppor- tunity of remarking to Dr. Bonsergent that this application of the red-hot iron was not free from danger-that there was a risk, from the want of docility in those operated on, of touching parts which ought not to be touched, and of so producing deep and extensive sloughs of mouth, cheeks, or lips. To this objection my colleague replied, that my fears were ground- less, and the dread of being burnt, which the patients themselves experi- enced, made them open the mouth wide enough to enable the operation to be performed with the greatest ease. I witnessed some successful results ; but still there was nothing in these cases to make me a convert to the treatment by the actual cautery, which seemed to have too brutal an ap- pearance, and to be a very dangerous proceeding, notwithstanding the opinion to the contrary held by my honorable colleague. The recent writ- ings of Dr. Valentin have failed to reconcile me to the use of the actual cautery in diphtheritic sore throat. It is quite a different thing when the diphtheria is cutaneous, anal, or vulvar, or when the affection we have to treat is stomatitis of the gums or mouth. In such cases the actual cautery has seemed to me to be of real utility; and in such cases, you have pretty frequently seen me employ it. In the treatment likewise of laryngeal diphtheria, cathartics and caus- tics, insufflation of powdered alum and tannin, cauterization with solution of nitrate of silver or sulphate of copper, and cauterization with hydro- chloric acid may be employed. A child, for example, begins to have a croupy cough, but as yet has not croup: false membranes have not yet been formed in the larynx : there is only an incipient diphtheritic inflammation, but before twenty-four or forty- eight hours have passed, the formation of false membrane will have taken place. Under such circumstances, therefore, the indication is to prevent their formation, by modifying the inflammation in which they originate; and this is to be done by applying catheretics to the superior orifice of the larynx, and to the larynx itself. The following method has been practiced by Bretonneau and me. We charge a tube with powdered alum, and introduce it far down into the pa- 416 TREATMENT OF DIPHTHERIA AND CROUP. tient's throat: after making him depress the tongue in a suitable manner, the insufflation is performed and repeated several times in rapid succession. By acting thus, a time comes when the patient is forced to draw in a full breath, and with it some of the alum necessarily passes into the respiratory passages. To accomplish cauterization with hydrochloric acid, nitrate of silver, or sulphate of copper, it is sufficient to introduce behind the epi- glottis a sponge soaked in the fluid caustic; once the sponge has been brought into contact with the aryteno-epiglottidean ligaments, it ought to be pressed against them in such a way as to squeeze out a little of the fluid caustic: the presence of the sponge excites convulsive inspiration, by which means the medicinal agent is made to enter the larynx. It must be ad- mitted that these therapeutic measures are very imperfect, and lead to very uncertain results. Inhalations of the vapor of hydrochloric acid, for a short time practiced by Bretonneau, are not easily accomplished : they also labor under the heavy drawback of having sometimes induced violent bronchial inflammation, and even peripneumonia. Their employment has now been generally abandoned. Catheterism of the larynx, by enabling the application of medicinal agents to be made directly to the larynx, is an efficacious practice. I do not refer to catheterism as practiced by Dr. Green, of New York, with a long piece of whalebone, armed with a sponge at its extremity. The plan devised a few years ago by Loiseau, of Montmartre, for the treatment of croup, is much more reliable. Although Professor Dieffenbach, in 1839, made use of the same method at the Charity Hospital of Berlin, Loiseau is not the less entitled to the honor of being its inventor, for when the idea suggested itself to him, he was entirely ignorant of what had been done by the Ger- man surgeon. Loiseau's method is this: he arms the first two phalanges of the index finger of the left hand with a bent metallic finger-stall, which leaves free the last joint and the distal phalanx. The finger thus protected is carried down into the throat as deep as possible, and with the extremity of the finger the epiglottis is raised. This being accomplished, nothing is easier than to introduce an instrument into the larynx. The instrument which Loiseau at first employed was a bent stem, armed with a receptacle for the solid nitrate of silver: he afterwards used a hollow sound resem- bling the laryngeal insufflator of Chaussier, an instrument which is bent, pierced with two eyes, cylindrical, broad at its upper extremity, and which gradually narrows towards a bent and abruptly flattened extremity. The affected parts can then be operated on by caustics, either by introducing through the catheter a whalebone rod to the end of which is attached a small sponge soaked in the caustic fluid, which is pressed out through the eyes of the catheter, or by injecting a caustic solution through the instru- ment. This latter proceeding some of you may recollect seeing me employ in the case of a little girl of four years of age, whose case was published in the Gazette des Hopitaux, of 31st October, 1857. When we consider how easily a fit of suffocation is caused by a foreign body touching the upper orifice of the larynx, we are apt to be frightened at the idea of introducing an instrument into the interior of that organ : there is much more reason to dread a suffocative attack, when liquids are injected into the air-passages. The only part of the operation which is painful to the patient is the seizure and elevation of the epiglottis. With reference to catheterism it may be stated, that the injection of even a con- siderable quantity of caustic fluid is well borne. These facts may undoubt- edly be thus explained. Catheterism is not the introduction of a foreign body which by its presence tickles and excites the orifice of the larynx, TREATMENT O*F DIPHTHERIA AND CROUP. 417 but of a foreign body which rapidly traverses and in fact forces the pas- sage. Now, if we suppose that the sentinels-if I may for a moment use that figurative expression-if we suppose that the sentinels, placed at the entrance of the air-tube, whose constant duty it is to prevent the admission of foreign bodies which might otherwise accidentally get in, are prevented from being of any service in consequence of the passage being forced, we see how it is that, unless the calibre of the tube be obstructed, suffocation will not be induced. In respect of the injection of liquids, it may be stated, that we know from experiments on animals that the trachea is very toler- ant ; and that caustic injections frequently provoke neither suffocative fits nor even coughing. We may also, following the practice of Green, but carrying it out by a surer plan, by directing the instrument along the finger which holds open the laryngeal orifice, by following the method of Loiseau, we may intro- duce in a direct manner a stiffish whalebone rod armed with a small sponge soaked in a caustic solution. With this apparatus the larynx may be swabbed out in such a way as to free it from false membranes. When the false membranes resisted this treatment, Loiseau was in the habit of de- taching them by the aid of flat curved forceps. The method of Loiseau is certainly very ingenious, and in submitting it to the judgment of the Academy, he cited numerous cases in which he had obtained remarkable results.* Upon several occasions I have had an opportunity of witnessing its successful application; and among others in a child, a patient of my friend Dr. Gros, who communicated an account of the case to the Medical Society of the Hospitals on the 28th July, 1858.f I myself have only once had recourse to catheterism: the patient was a little girl of whom I am by and by going to speak to you. In her case you had an opportunity of judging of the harmless character of the opera- tion, and the facility with which it is performed. Loiseau's cases deserve attention, although perhaps the narrator has exaggerated the importance of the bearing of some of them. Cauteriza- tions of the larynx may, in my opinion, under certain circumstances, be productive of great benefit. Perchloride of iron has been recently brought forward as a specific remedy in diphtheria. Although I have not as yet had sufficient experience to entitle me to give an opinion as to the exact value of this medicine, I have employed it in a sufficient number of cases to justify me in refusing to admit that it possesses the specific properties which some practitioners have ascribed to it. It cannot be denied, however, that it has rendered real service both in my hands, and in those of the honorable physicians who first sounded its praises. You have seen me use it in the form of concen- trated solution as a caustic agent, with a view to modify the character of the surfaces covered with diphtheritic exudation. You have also seen me administer it internally in a potion containing from 4 to 10 grammes [62- 155 grains] which the patient takes during twenty-four hours. But its action is perhaps not more special than that of other ferruginous medicines, which, like it, are indicated in the general treatment of diphtheria. Its extreme solubility, however, gives it a certain advantage over other prepa- rations of iron. I have insisted, gentlemen, upon the uselessness, the danger of antiphlo- gistics, which I absolutely interdict in the treatment of diphtheria. In * Loisea.it : Bulletin de Imperials de Medecine, 1857, t. xxii, p. 1139. f See the " Union Mddicale" for 14th September, 1858. vol. I.-27 418 TREATMENT OF DIPHTHERIA AND CROUP. passing before you in review the other different medicinal agents recom- mended in diphtheria, I have endeavored to show that mercurials and alkalies, in so far as they are alterative remedies, present more disadvan- tages than advantages. I also told you, that certain medicines, such as sulphate of potash and polygala senega, to which for a time anti-diphtheritic properties were attributed, have justly fallen into oblivion. I have laid great stress upon the question of blisters, and have implored you never to employ them, their action in diphtheria being deplorable and perilous in the highest degree. Finally, I stated that I had come to the conclusion, after the teaching of a long experience, that topical treatment by astrin- gents, catheretics, and caustics, is pre-eminently the best treatment of diph- theritic affections; but I did not say that it could by itself cure the disease. General treatment constitutes an important part of the treatment of diph- theria. It ought to be essentially tonic and restorative, as in all diseases in which from the first the vital forces seem to be disturbed and depressed. Alimentation occupies the first place in the general treatment; and I have observed that the severer the attack, the more imperative is the necessity to sustain the patients with nourishing food. Loss of appetite, that is, disgust for every kind of food, is one of the most alarming prognostic signs. We must try to overcome this loathing of food by every possible means: and to get nourishment taken, I sometimes do not hesitate, in the case of children, to threaten punishment. When the patient retains his appetite for food, there is good hope of recovery. There are no rigid rules in respect of the choice of food. We are often obliged, in some individuals, to satisfy the strangest possible caprices of taste. *In pseudo-membranous sore throat, when there are pain and diffi- culty in swallowing, I give nourishment in a semi-solid state-thick soups, farinaceous food, chocolate made with water, creams, boiled eggs, and such 'like alimentary articles. As soon as possible, I begin a more reparative animal diet. The pharmaceutical agents which I employ in the general treatment are the preparations of cinchona and iron. I generally give the powder of yellow cinchona in doses of from one to two grammes [15? to 31 grains] in a cup of cafe noir, the object of the coffee being to mask the bitterness of the drug, and facilitate its digestion. For those who have a repugnance to this preparation of bark, and also when I wish to obtain a more speedy effect, I substitute sulphate of quinine for the powder of cinchona, admin- istering it also in a similar manner in coffee. I am likewise in the habit of prescribing the wine and syrup of cinchona. The preparations of iron which I prefer are those which are the most soluble, such as the per- chloride, the citrate, and the tartrate. TRACHEOTOMY IN DIPHTHERIA. 419 Tracheotomy. ill the present day no one can deny its Utility and Necessity.-Mode of Op- erating.- The Dilator.- Operation ought to he very Slowly Performed: Dangers of Rapid Performance.-Dressing. - Cauterization of the Wound.-The Neckcloth.- General Treatment.-The Chances of Success are the Greater, the Less Energetic the Anterior Treatment has been.- Alimentation of the Patients.-Removal of the Canula-Infected Canute. -A Condition favorable to Success is to Operate as Soon as Possible.- Unfavorable Conditions.-Death is Certain in Malignant Diphtheria.- Death is Almost Certain in Children under Two Years. Gentlemen: Let us assume that all treatment has failed to prevent the propagation of diphtheria to the air-passages, and that croup exists- that we have in vain attempted to combat the disease by the measures which I have described to you, and which I must say are more frequently unsuccessful than successful; or let us suppose that we are called to a patient in whom there already exists confirmed croup, in whom asphyxia threatens, and in whom death is inevitable: under such circumstances, there still remains one important resource,-tracheotomy. It was recom- mended by Stoll,* who, however, seems never to have performed it. John Andree a London surgeon performed it for the first time, and with success, in 1782. The subject operated on was a child, an account of whose case Jacob Locatelli sent to Borsieri, by whom it was published in his Insti- tutes, j* At the beginning of the present century, Caron, a French physi- cian, renewed the praises of tracheotomy, although he had only performed it once, and that unsuccessfully. It is in reality to Bretonneau that the merit of a first success is due; for John Andree's case has been the subject of much controversy. After two unfortunate attempts in 1818 and 1820, the illustrious physician of Tours, undismayed by these disappointments, made a third attempt in 1825. The patient was the daughter of one of his most intimate friends, the Count de Puysegur, who had had three chil- dren carried off by croup: this time, Bretonneau had the good fortune to save his patient. I believe I was the second person who, following the example of my master, performed tracheotomy in laryngeal diphtheria, and the second also to record a successful result of the operation. This case is now of old date. The child upon whom I operated was the son of a man whose name has in recent times made a certain noise-Marcillet, the magnetizer of Alexis, the somnambulist. I published the history of this case in 1833.1 I have now performed the operation in more than two hundred cases of diphtheria and I have the satisfaction of knowing that one-fourth of these operations were successful. Others after me have pur- sued the same practice, and have met with success. It was at the Children's Hospital that I gave the first impulse to this practice. Now, there is not an interne who fulfils a year of duty at that establishment without having opportunities of snatching from the grave several children irrevocably lost but for his judicious operative intervention. The proportion of successful cases has greatly increased since, profiting by past experience, we have attached great importance to the management of the case after the opera- * Stoll : Aphorismes sur 1'Angine Inflaminatoire. t Borsieri : Tome iv. Angina Trachealis, § cccexxxvi. j See Journal des Connaissances M6dico-Chirurgicales for the month of Sep- tember, 1833, Number First. 420 TRACHEOTOMY TN DIPHTHERIA. tion. The details of the mode of management I shall, have forthwith to enlarge upon. At the Children's Hospital, in the Rue de Sevres, the pro- portion of successful cases in recent years has been more than a fifth, a large proportion, when we bear in mind the social position of the children who are brought to the hospital, and the deplorable treatment to which they have been subjected by midwives, quacks, and old women, whose ad- vice is preferred by the lower classes to that of medical practitioners ; and then again, still more, when we recollect the dangers of the hospital itself, where the unfortunate children operated on are in a hotbed of formidable and varied contagion, as is shown by the great frequency with which an attack of scarlatina, measles, small-pox or hooping-cough supervenes as a terrible complication, when all seems to be progressing favorably after tracheotomy. My impression is that one-half of the cases operated on in private practice ought to prove successful, provided, of course, the opera- tion is performed under conditions in which recovery is possible. I shall tell you what these conditions are. The successful results which are pro- claimed on all sides speak so loudly in favor of operating, as to bear down all opposition ; and I do not stand alone in preaching that there is an im- perative duty imposed on the practitioner of performing tracheotomy, a duty as obligatory as tying the carotid artery when that vessel has been wounded, although death quite as often as recovery follows the operation. In the early days of tracheotomy in croup, there was a great deal of opposition to it; but at present, it has no opponents except among the wayward, ill-dis- posed, or ignorant. There is now no longer anything serious in the opposi- tion : and henceforth the proceeding must be looked on as one conquest more of the healing art added to the ordinary practice of therapeutics. Tracheotomy is opening the windpipe so as to allow air to enter when the natural orifice of the glottis is almost obliterated. The professor of operative medicine will pardon my encroaching for a moment upon his territory, that I may describe to you, if not in accordance with the rules of surgery, at least after my own fashion, an operation which physicians are more frequently called upon to perform than surgeons. The instruments required are a sharp-pointed somewhat convex bistoury, and a probe-pointed bistoury; two blunt hooks with good handles, or fail- ing them two hair-crimping pins; a dilator, like a sort of dressing-forceps, curved at the extremity, with the two limbs forming at the end of the in- strument a sort of spur projecting outwards, so as to enable it to fasten the lips of the tracheal wound, and prevent their displacement by the respi- ratory movements. The use of this instrument is to dilate the opening made in the trachea, so as to allow the tube to be introduced. The tube ought to be double-an external and an internal canula. In the expanded extrem- ity of the external tube are two apertures to receive tapes, which are tied at the back of the neck, so as to keep the apparatus in its place. Besides these two apertures, there is in the upper part of the expanded extremity of the external canula a sort of key which fits into a slit in the correspond- ing part of the internal canula. The internal, which necessarily has a less diameter than the external canula, has two ears projecting from its ex- panded extremity, by which it can be held when it is wished to take it out or replace it: it is fixed to the external canula by the little key which I have mentioned, and which can be easily opened and shut. The diameter of the tube ought to be considerable; it can never be too large, provided the instrument can easily enter the trachea. Its curve ought to form a quarter circle; this is the principle upon which all these instruments are now made by M. Mathieu, who adopted the fixed standard to avoid incon- veniences which I pointed out to him, the curve of the different tubes pre- TRACHEOTOMY IN DIPHTHERIA. 421 viously shown to me being either too great or too small, in consequence of the workmen having always departed from the exact form of the model placed in their hands. That the tube be double, is an absolute necessity; and when we see the manner in which Van Swieten insists on the necessity of using a double tube, and that he does so on the authority of the English author, George Martin, it is remarkable that the precept was forgotten ; it is strange, too, that although the double canula was recommended by Bretonneau, who from his earliest operations employed an uncurved double tube, I myself for years employed the single tube.* The dilator is indispensable. I have only once lost a child during the operation; the patient was under the care of my honorable colleague, Dr. Barth. I went to the consultation ignorant of the state of matters, and found the child dying. Dr. Barth was prepared with tube and bistoury. From not having a dilator, I was unable to keep aside the vessels as I should have wished: I felt about with my finger for a long time before I was able to make an entrance into the trachea, and during that time a great quantity of blood entered the bronchi and suffocated the patient: this could certainly not have happened, if I had had a dilator which I could at once, on making the incision, have introduced into the windpipe. When a dilator cannot be obtained, recourse may be had to a plan devised by Dr. Paul Guersant: it consists in arming the tube with an ordinary gum- elastic catheter, projecting some centimetres 'from the inferior opening of the tube. You can understand how much the manual proceedings will be simplified by this contrivance. The gum elastic catheter is easily intro- duced into the tracheal wound, the finger being used as a conductor; and then all that is required to get the canula into position is to cause it to slide upon the catheter. I shall now describe the operation. The patient is laid on a table, on which there are a mattress and several folds of a blanket: a doubled up pillow, or better still a rouleau made with sheets, is placed under the shoulders and back of the neck, so as to put on the stretch the anterior region, and bring the trachea as much as possible into relief. This is un- doubtedly a very distressing position for an individual in a state of asphyxia, but it has not to be long endured. An assistant placed behind the patient is appointed to hold the head firmly; another assistant, placed opposite the operator, is charged with keeping aside the different layers of tissue and the bloodvessels, by means of a blunt hook held in the left hand, while he is on the alert to use, when required, the right hand in sponging the wound with small sponges placed beside him ready for use. The assistance of other persons is also needed to prevent the patient moving. Finally, that I may omit nothing, let me add, that if you operate at night, there must be some one to hold for you a candle giving a strong light. If the operation is per- formed in full daylight, the patient ought to be placed directly in front of a window of the room, the feet being next the window, so that the light may fall full on the neck. * Van Swieten: " Maj us incommodum inveniabatur, dum mucosi humoris copia per tubi orificium effluens, ejusque lateribus adhserens, sensim inspissata angustabat tubi cavum, liberamque aeri ingressuro viam impediebat; unde coge- batur Georgius Martinius tubum educere et mundare. Multuin quidem hoc caveri potest, dum alterum tubi extremum multo latius liberum humoribus exitum per- mittit: interim tamen non incongruum videtur, uti monuit Celebris auctor, si duplex foret tubulus in asperam arteriam dimissus, quorum major alterum exciperet." . . . " Hoc enim commodi a duplici tali tubo haberetur, quod interior exirni posset et mundari, dum exterior et major interim in vulnere maneret."-[Commen- taries a 1'Aphorisme 813 de Boerhaave. Paris: 1757, t. ii, p. 628.] TRACHEOTOMY IN DIPHTHERIA. 422 These precautions taken, the operator standing on the patient's right- observe, I say the right and not the left, because otherwise, unless he be ambidexter, he will be embarrassed by the projection of the chin: the operator, then, standing on the right of the patient, grasps the tracheal region with the left hand, when with the right hand he makes an incision in the median line, from the cricoid cartilage to within a little of the sternum. The importance of making the incision in the median line is so great, that if this rule be neglected, the operator is liable to be very much embarrassed during the whole of his proceedings. I recommend those who have no pretensions to surgery to draw on the skin the proper course of the bistoury with ink or a cord blackened in the flame of a candle. Having incised in succession the skin and the cervical aponeurosis, there is reached a small white mark indicating an interstice between the muscular masses. The blood now flowing is soaked up by the sponges; the operator then cuts in the line of the small w'hite mark, separating the sterno-hyoid and sterno- thyroid muscles, which, by means of the blunt hook in his left hand, are held aside, while, at the same time, the assistant who is in front of the ope- rator separates them from each other. This is the point at which difficulties begin. The isthmus of the thyroid gland has now been reached ; its size and position vary so much, that it is sometimes found covering the first rings of the trachea, and at other times is much higher up. Lower down we find the thyroid plexus of veins, and Neubauer's artery when it exists. Now is the time when the operator must bear in mind the cardinal precept, to avoid wounding the bloodvessels. If he see a large vein he must dissect it out, and draw it to one side with the blunt hook. If the left subclavian vein, gorged with blood, shows itself in the jugular fossa, it may be depressed and protected by a finger, and the terrible accident be thereby avoided which would result from its being wounded. For still stronger reasons attention ought to be paid to the trunk of the brachio-cephalic vein, which in chil- dren often projects considerably beyond the substerual fourchette. As soon as the trachea is brought into view it ought to be denuded, and a small incision made in it, as near as possible to the cricoid cartilage, the bistoury being directed upon the nail of the index finger which is placed at the bottom of the wound. A hissing noise indicates that the trachea has been opened: the sponge is now used, and then, by means of the probe- pointed bistoury, the incision is forthwith enlarged. If the original opening has been made far from the cricoid cartilage, it must be enlarged by cutting from below upwards, so as to avoid the trunk of the brachio-cephalic vein. Many practitioners prefer opening the crico-thyroid space, cutting the cri- coid cartilage or the two first tracheal rings, in accordance with Heister's plan. It is evident that, by proceeding in this way, we penetrate the larynx itself; and that-as often happens-if the tube remain some weeks in the wound, the result will be partial necrosis of the cricoid cartilage, and even of the thyroid cartilage, the probable source of serious ulterior consequences, among which may be mentioned an irremediable alteration of the voice. Let it be understood that I am now speaking of what ought to be done in cases of croup occurring both in adults and in children ; for, afterwards, wdien I shall have to speak to you of tracheotomy in other laryngeal affec- tions, I shall have to point out that in the more aged a different method of proceeding is sometimes required. In cases of croup it is only necessary to open the trachea. I cannot, gentlemen, too strongly insist upon the necessity of dividing the tissues layer by layer, holding aside the vessels and muscles by the blunt hooks, and entirely denuding, before opening, the trachea : I lay great stress TRACHEOTOMY IN DIPHTHERIA. 423 upon the absolute necessity of proceeding very slowly. If, even during the operation, the child has a suffocative attack, stop to allow him to struggle, and permit him to sit up that he may get his breath : you may thus perhaps lose a minute, but of that you need not be afraid. I have never seen an accident arise from too much slowness; but I have often witnessed the difficulties and dangers of a too nimble tracheotomy, even when performed by an able operator. Hence it is, therefore, that I denounce with all my strength the expedi- tious mode of operating lately recommended by Chassaignac, which consists in fixing the larynx by means of a tenaculum, and then penetrating the trachea by a direct puncture through the skin and subjacent parts. This is not a new method of performing tracheotomy. In 1586 Sanctorius, who seems to have been the first to practice bronchotomy, proposed puncture of the trachea with the trocar which he had invented for performing abdom- inal paracentesis. In 1748 Garengeot recommended laryngocentesis as being very superior to the operation by which we reach the trachea step by step: he, however, advised that the skin, without disturbing the muscles, should be incised in the first instance, at least in thin subjects.* Direct puncture, without previous incision, is also recommended by Heister,f because it is more expeditious, and because it saves suffering to the patient, as one stroke makes the puncture with the trocar and introduces the canula into the windpipe. Decker, Bauchot, Barbeau-Dubourd, and Richter had thought of bronchotomy, with a view of rendering the operation safer and quicker. Van Swieten, in the 813th Commentary, which I have just referred to, speaks at some length of bronchotomy, which he denounces as dangerous, after having performed it experimentally on the dead body, and on living animals.| A. Berard, who also had invented a proceeding similar to that of Heister, ultimately discovered that the quickest was not always the best method: towards the close of his career, he renounced his expeditious pro- ceeding for the more common and safer operation. Dr. Paul Guersant likewise adopted, for a short time, the expeditious method ; and although he operates better and more quickly than those of us who are not surgeons, he proceeds sufficiently slowly to avoid the serious mishaps to which I have directed your attention. On the one hand, there is the danger of fixing the larynx, for, as Dr. A. Millard has sensibly remarked in his excellent thesis,§ and as Lenoir|| had previously said in 1841, by impeding move- ments connected with the exercise of a function already threatened, you run the risk of accelerating asphyxia and death; and on the other hand, there is the risk of exciting fatal hemorrhage, if by accident the instrument wounds a vessel from encountering an anomalous distribution of arteries, as hap- pened in a case communicated to me by Dr. Richet. In a little girl, in whom he had operated for croup, he was obliged, just at the moment he was going to open the trachea, to divide an artery almost as large as the radial: it was an anastomosis of the two inferior thyroids. The bleeding was stopped by the application of a ligature to each of the extremities of the divided vessel; and the able operator had to congratulate himself upon * Garengeot : Operations de Chirurgie, t. ii, p. 447 et 448. j Heister: Institutions de Chirurgie, t. iii, p. 153, annee 1770. | Van Swieten: " Tentavi aliquoties in cadavere etin vivis animalibus hanc methodum, sed videbatur mihi admodiim difficilis, et non carere periculo, ne quan- doque valida vi adactum instrumentum deviaret, unde crederem priorem methodum, licet magis operosam, praeferendam esse." [Commentaria in Boerhaavii Aphorism, de coognosc. et curand. morbis: Aph. 813, t. ii, p. 627.] $ A. Millard: De la Tracheotomie dans le cas de Croup. Paris, 1858. || Lenoir: De la Bronchotomie. Thhse, 1841. 424 TRACHEOTOMY IN DIPHTHERIA. the slowness with which he was in the habit of performing tracheotomy. In another case I found the left carotid artery arising from the trunk of the innominata, and crossing the trachea. Again, it is not easier to punc- ture the trachea through the skin than from the bottom of a wound; still, the instrument may deviate, and, in place of entering the windpipe, may penetrate the oesophagus, an accident which occurred to my colleague Dr. A. Berard. Finally-what ought to be done, if, at the moment of intro- ducing the tube, an obstacle is presented by the false membrane lining the trachea? How are you to see what to do at the bottom of a deep narrow wound inundated with blood? Under such circumstances death will be inevitable. Some of you, who have followed my clinic for several years past, will recollect that the very case I have now supposed actually occurred in our wards. On the 27th May, a little girl of four years of age was brought to me suffering from croup: as she was at the last extremity, I lost no time in resorting to tracheotomy. Just as I had laid bare the trachea, I cut a somewhat large thyroid vein: with the view of arresting the hemorrhage, which was rather abundant, I hastened to introduce the canula. This, however, did not re-establish respiration: there was a great degree of suffo- cation, and the face of the little patient was frightfully livid. I withdrew the canula, and introduced the dilator. The child was in a state of appar- ent death, respiration was suspended; and the pupils were dilated, indi- cating that asphyxia had proceeded very far. We then caused the thorax to perform blowing movements: after a minute and a half or two minutes, an interval which seemed dreadfully long, we saw the patient make some grimaces; then, a deep inspiration drew air into the chest, and brought back life. An occurrence had taken place similar to others I had observed during my long practice. False membrane coated the larynx, trachea, and bronchi; and whilst I was inserting the canula, this false membrane, being torn, was compacted by my instrument in such a way as to com- pletely obstruct the passage of air. After I had withdrawn the canula and introduced the dilator, respiration was re-established: the false membrane was then seen at the opening of the trachea: I removed by the forceps a large piece of it, which was branched at its inferior extremity. When the canula was readjusted in its place, other portions of false membrane, coming from the bronchial tubes, passed out through it, their expulsion being pro- moted by coughing excited by tickling the trachea with a feather. These portions of false membrane were tubular, and their calibre showed that the diphtheritic affection had reached far down into the lungs, so that although respiration was re-established, there was no permanent advantage to be hoped for from the operation. The child died during the night. The expeditious method exposes the patient to another accident, which, it is true, may also sometimes arise when the safer operative proceeding is followed. I refer to emphysema of the cellular tissue, resulting either from want of parallelism in the incisions through the soft parts and the trachea, or from the opening into the tracheal wound being so narrow as to make the introduction of the canula a difficulty. There is nothing in this em- physema to occasion anxiety. When limited to the neck and the neighbor- hood of the wound, it quickly disappears, and may be looked on as an acci- dent of no consequence. But when it is so extensive as to invade the chest, it tends to embarrass the breathing: if it reach the face, it has the addi- tional drawbacks of disfiguring the patient and frightening the family. It sometimes attains extraordinary proportions, becoming almost general, as occurred in a case observed by Dr. Millard: it is then a very serious com- plication. In addition to the dyspnoea which it occasions, it gives rise to TRACHEOTOMY IN DIPHTHERIA. 425 so much swelling of all the tissues of the neck, and consequently makes the wound so deep, that the common tracheal tubes are too short to reach the trachea, and it becomes necessary to have recourse to very troublesome expedients. Operate slowly, therefore,-very slowly. When the trachea is opened, the operation is not completed : what remains to be done, though not the most difficult part of the proceeding, is that which demands the greatest amount of coolness and presence of mind. This is the moment when the blood deluges the bronchi, when the venous hemorrhage, so far from stop- ping, becomes more abundant, in consequence of the respiration being more difficult. It is now necessary at once to take the dilator, which ought to be lying ready to hand, and introduce it shut between the lips of the wound in the trachea, and then open it moderately by separating its rings. This manipulation, however easy it may seem from description, does not the less require some practice. I have very often placed the extremity of the in- strument between the muscles, and have only introduced one of its branches into the trachea. Here again, it is essential to proceed slowly : it is neces- sary to go as deep as possible. When the dilator is properly placed, the air enters easily: the blood, mucus, and false membrane are discharged ; and respiration, in general, becomes easy. At this stage of the operation, the assistant who holds the patient's head ought to elevate it a little in front, so as to facilitate the introduction of the dilator, by relaxing the edges of the wound, and so favoring the discharge of the blood and mucus. If there is taking place a somewhat abundant venous hemorrhage, as in the case I have just related to you, at once introduce the canula, and when you have done so, the bleeding will immediately cease. The dilator serves as a director in introducing the canula, which ought to be previously provided with a caoutchouc shield, or covered with oiled silk, so as to prevent its expanded part from causing excoriation of the skin of the neck. This stage of the operation is often very difficult: some- times the operator misses the opening in the trachea, and buries the instru- ment in front of it, in the cellular tissue. The entrance of the tube into the windpipe is known to have taken place by the escape of air and mucus from its external orifice, and by the facility with which respiration is per- formed. It is indispensable that the canula be of sufficient length to ex- tend into the trachea one or two centimetres beyond the inferior angle of the opening which has been made into that passage. If too short, it is displaced by coughing, and gets out of the trachea into a sort of pouch which always exists in front of it: in a few minutes, the patient dies as- phyxiated. Thrice have I had to deplore this frightful accident, though I had left my patients after the operation, under the charge of pupils who were not without experience. To avoid similar catastrophes, it is essential to secure the canula firmly in its place by tapes carried round the neck. Provided the canula be introduced into the trachea, it really matters little how that has been accomplished. Whether the operation has been performed with more or less dexterity, or with more or less rapidity, the result is the same, provided there has not been hemorrhage. Loss of blood has a very unfavorable influence upon the results of the operation. Treatment in relation to tracheotomy is a subject which has still to be considered. This, which is entirely a medical question, is now looked upon as of paramount importance : nor is this surprising when we consider that some lose nearly all their patients, while others save a third or even a half. I should be doing wrong, were I only to speak of that which has to be done : great importance must be conceded to the treatment of the cases prior to the operation. The majority of physicians are fortunately agreed 426 TRACHEOTOMY IN DIPHTHERIA. that remedies intended to act on the entire economy are often useless, and that the chances of success are all the greater, the less energetic the therapeutic measures which are employed ; that, in particular, blisters are very objectionable, as I have often pointed out: consequently, they do not exhaust their little patients by the abstraction of blood, and they abstain from using blisters. I am convinced that the greater success which has attended tracheotomy in recent years is due to the sounder principles of treatment which during that period have been pursued by my professional brethren. Before entering upon the subject of consecutive treatment, I ought to mention some details regarding the manner of dressing the wound, to which it may appear perhaps that I attach undue importance; but the older I grow, the more do I become convinced that attention to minutiae is of much more importance in therapeutics than is generally believed. I have already mentioned the importance of interposing a piece of caoutchouc or oiled silk between the expanded part of the tube and the wound in the trachea, so as to prevent the occurrence of irritation ; and I have referred to the neces- sity of keeping the tube in its place by tapes or bands. Other minutiae are deserving of notice. The neck ought to be surrounded by a knitted comforter or with a large muslin neckcloth, so that the patient may expire into this thick material, and inspire air impregnated with the steam supplied by his expiration. This is a rule of fundamental importance; by attending to it the interior of the canula as well as of the trachea is prevented from becoming dry: irri- tation of the mucous membrane is guarded against, and there is also pro- vision made against the formation of coriaceous crusts similar to those which form in the nose in coryza-crusts which become detached as tubes or frag- ments of tubes, leading to terrible fits of suffocation, and sometimes causing death from occlusion of the canal. Before Dr. Paul Guersant and I had adopted this plan, we lost a great many of the patients we operated on from catarrhal pneumonia: this is now a much less usual cause of death. Prob- ably, the introduction of warm moist air into the bronchi is a condition exceedingly favorable to the prevention of pneumonic attacks. The plan of covering the neck with a cravat was adopted in old times. The object, however, for which it was recommended was to prevent the entrance by the canula of dust and small bodies which might be floating about in the air. As G. Martin remarked, this fear was chimerical. But in addition to the precaution of wearing a cravat, from their point of view, an unnecessary precaution, the old physicians advised the patients to be kept in warm rooms: for, said they, the cold air may prove injurious, inas- much as the air which reaches the lungs by ordinary respiration is warmed in passing through the mouth and nasal cavities. This was the opinion enunciated by Van Swieten.* Garengeot, however, grasped the true indi- cation when he recommended the placing of cotton over the orifice of the * Van Swieten: "Solliciti pariter fuerunt plerique hujus operationis descrip- tores, ut caverent ne una cum aere pulvisculi in illo volitantes patulum tubi orificium intrarent libere ; bine gossypio, linteo carpto, spongia, &c., tegi voluerunt extrorsum patens tubuli orificium. Martinius tamen usu didicit nullarn notabilem inde noxam aegro accidere, licet non tegeretur tubuli orificium, quamvis etiam in domo non adeb nitida decumberet aeger. Si tamen inde quid metueretur, posset hoc facile evitari, si collo circumduceretur laxe rarum linteum, spleniis ita in vicina tubuli dispositis, ut illud quidem tegeret tubi orificium, non tangeret. Expediet tamen ut aer parum calidior sit in loco quo decumbit aeger, cum frigore suo nocere plus posset quam dum communi respirationis via in pulmonem trahibur, semper in transitu vel os vel nares calescens utcumque." \_Loc. cit., p. 628.] •' TRACHEOTOMY IN DIPHTHERIA. 427 canula, to modify the air entering the trachea, or better still, placing over the orifice of the canula a pledget of fine lint or a piece of linen of rather-loose texture. In our day it has been proposed to evolve steam in the patient's room, but this is certainly neither a simpler nor more convenient method than the cravat. There is still another practice, without having recourse to which recovery seldom occurs. I refer to cauterization of the wound. Immediately after the operation, and during the four following days, all the cut surfaces ought to be vigorously rubbed with solid nitrate of silver. By this means an ac- tion very much to be dreaded is prevented-viz.: the wound being affected with diphtheria, and becoming covered with thick and fetid false mem- brane. Moreover, the specific diphtheritic inflammation, spreading to the surrounding cellular tissue, often originates in that situation phlegmonous erysipelas of a bad character, leading to local gangrene, or at least to vio- lent symptomatic fever, and general poisoning of the system, a condition from which recoveries are rare. Dr. Millard states in his thesis that he never performs this cauterization at the time of the operation; and accord- ing to information which I have obtained from one of the ministering sisters of the Hospital of the Rue de Sevres, possessed of great practice and experience in the treatment there followed by my colleagues, it is never performed till, at the soonest, twenty-four hours after the operation ; if the child have fever, it is allowed to subside before cauterization is performed, and it is also considered necessary that the child be not intractable. I am opposed to these rules of practice, because I have witnessed the bad conse- quences which result from observing them. After the fifth day, the surface of the wound is so modified that the complications which have been referred to are no longer to be dreaded. When once the operation has been performed, the first care of the phy- sician ought to be the nourishment of the patient. Alimentation, gentle- men, as I have reiterated on several occasions, is the chief remedy in the majority of acute diseases, and particularly in those of childhood. There can be. no doubt that abstinence, as prescribed by Broussais, and as still inculcated by a great many physicians, who, unable to put off the old man, retain too strongly the prejudices of their early medical education, is one of the deadliest complications of disease, that which is most calculated to keep up the contamination of the system, the most calculated to promote the absorption from without of miasmata and of morbid elements formed from the diseased body-the most opposed to that power of resistance which is the great well-spring of convalescence and of ultimate recovery. I do not mean to say that it is necessary to cram the little patients with food: I only wish to say that their appetite for food, if it exist, ought to be grati- fied, and that if they have a repugnance to it, it is then essential to force them to take a little. I revert to this point, upon which I have already spoken when discussing the general treatment of diphtheria: do not be afraid of employing intimidation. Many is the time, that, arming myself with an assumed expression of great severity, I have obliged children to take food, and have thus paved the way for recovery, which otherwise could not have taken place. The alimentary articles which I most insist on are milk, eggs, cream, chocolate, and soup. If necessary, the oesophageal tube must be used to introduce into the stomach the sustaining food which the child refuses to swallow. What I have now said sufficiently indicates that I absolutely interdict the continuance after the operation, of certain means, which before it, might be judged more or less useful, such as calomel, alum, emetics, and purga- 428 TRACHEOTOMY IN DIPHTHERIA. fives. Such remedies are quite incompatible with the nature of the alimen- tation which I recommend. It is a remarkable fact, that when once tracheotomy has been performed, there need no longer be entertained any anxiety regarding the diphtheritic manifestations of the pharynx or larynx which formerly it was imperative to attack by very active measures: they disappear spotaneously. It ap- pears that by the time the disease has reached the air-passages, it has ex- hausted itself; and that if by admitting air to the lungs, by tracheotomy, the patient be prevented from dying, recovery will take place. I speak of the pharyngeal and laryngeal, and not of the cutaneous manifestations; for the latter ought always to be most determinedly followed up and eradicated by the topical means which I have indicated, lest otherwise, they become, through absorption, the source of a deadly general poisoning of the system. When first I practiced tracheotomy, following Bretonneau's example, I was in the habit of prescribing the mopping out of the windpipe, as far down as it was possible to reach, with a small sponge fixed to the end of a piece of whalebone. I have long since discontinued this proceeding: I have likewise relinquished cauterization of the trachea, which I used to per- form by applying to it a sponge soaked in a caustic solution, or by drop- ping into it some of that solution. These proceedings have seemed to be productive of inconveniences which were not counterbalanced by any real advantages. I may here add that the dropping in of the solution of chlor- ate of soda, as recommended by Dr. Barthez, was abandoned by that phy- sician himself, after he had made it the subject of a communication to the Medical Society of the Hospitals. The frequent cleansing of the internal canula is an essentially necessary precaution, so that the ingress of air may be as free as possible. I recom- mend that this cleansing should be performed every two hours. There still remains a word to be said on the last part of the treatment, which is one of some delicacy. I refer to the removal of the tube, and the final closure of the wound. I do not speak of Dr. Millard's method of temporarily removing the canula from the very first dressing, twenty-four hours after the operation. The idea of my intelligent young colleague is that by so acting, he assists the expulsion of bulky false membranes, which by being allowed to remain in the canula, may, by choking it up, induce fits of suffocation. Unques- tionably, in cases in which there is risk of suffocation, the removal of the tube is proper; but, under ordinary circumstances, I see no advantage in, far less any necessity for, this proceeding. In saying this, I am not the less decidedly of opinion that the sooner the better the canula can be finally removed ; but this can seldom be done before the sixth day : the cases are few in which the tube ought to remain after the tenth. There are cases, however, in which recovery takes place after the larynx has remained com- pletely closed for fifteen, twenty, or even for twenty-four days, as I saw in the case of a young girl. I have mentioned the case of a child who retained the canula for five years. That patient is still alive, but has a tracheal fistula. The tube ought to be removed at the end of the first week, care being taken not to make the child cry or be frightened. The poor little creatures who have been operated on are so much accustomed to breathe by the arti- ficial passage, that when it is closed, to facilitate the entrance of air through the larynx, they are apt to be seized with a paroxysm of fear, which finds expression in excitement and cries, leading to acceleration of the respira- tory movements. The larynx is, at this period, somewhat obstructed by slightly adherent false membrane, by the presence of mucus, or by the ex- TRACHEOTOMY IN DIPHTHERIA. 429 istence of slight swelling of the mucous membrane; and possibly, also, the laryngeal muscles may have lost the habit of giving harmonious response to the demands of the respiratory function : from these causes, there is often greatly embarrassed breathing. In the majority of cases, this embarrass- ment passes away pretty readily, provided the little patient can be tran- quillized : the accomplishment of this is more within the province of the mother than of the physician. The wound has now to be closed with strips of adhesive plaster. If the sound of the cough or the respiration, if the nature of the voice or the cry show that the laryngeal passage has become fairly pat- ent, the dressing is completed in such a way as to promote immediate union of the edges of the wound; but if the air does not enter in sufficient quan- tity, the adhesive plaster is not put on: the wound is, under such circum- stances, simply dressed with a piece of loose linen smeared with cerate, and the closing of the wound is delayed till next day. Should there be no pas- sage of air through the larynx, the canula must be replaced, another trial being made two or three days later. As soon as respiration is well per- formed with the artificial opening closed, the wound ought to be dressed two or three times a day: generally, the opening into the trachea ceases to exist at the end of four or five days: all that remains to be attended to is dressing the external wound till its closure, which soon takes place. The presence of the canula may occasion-and that sometimes with con- siderable rapidity-a serious occurrence, to which Dr. Henri Roger in par- ticular has called attention: I refer to ulceration of the trachea* From the researches of this intelligent observer, it appears that ulceration of the windpipe is a frequent consequence of the contact of the canula, and that the lesion varies from a mere superficial erosion to a complete perforation. Dr. Roger has observed that ulceration of the anterior is much more fre- quent than of the posterior wall of the trachea: it arises in the former case from the friction of the lower edge, and in the latter from contact with the curve of the canula. Complete perforation of the trachea by ulceration is obviously a very formidable accident: in two cases communicated by Dr. Barthez, nothing intervened between the canula and the brachio-cephalic artery except the muscular coat of the trachea: at other times, the tracheal lesion has caused the formation of abscesses and purulent sinuses: in any case, this ulceration becomes a new cause of loss of power from the suppu- ration which it induces. As these ulcerations are evidently caused by excessive friction, and as friction cannot be altogether avoided, the problem is, how to render it as moderate as possible. Dr. Roger first of all proposed to adopt the curve of which I speak, and then proposed to make the body of the canula move on its expanded extremity, so that in all the movements of the the body of the canula should move with the trachea, without rubbing against the side of the passage with which it is in contact, the friction being upon the expanded extremity of the canula, with which it is loosely articulated. In this way, the expanded extremity of the canula is solidly fixed to the neck; and the body of the instrument, which is in contact with the wound and with the internal surface of the trachea, moves upon the expanded ex- tremity. Since the publication of Dr. Roger's work, only jointed tubes have been used at the Children's Hospital, and since that time, also, ulcer- ations have been less frequent, as well as less serious when they, have oc- curred. Although I believe that the predominating bad character, and the special constitution of an epidemic, have much to do with the frequency * BofiER (Henri) : Des Ulcerations de la Traehee-artere Produites par le sejour de la Canule apres la Tracheotomie. [Archives Generales de Medecine, 1859.] 430 TRACHEOTOMY IN DIPHTHERIA. of the lesions pointed out by Dr. Roger, I do not hesitate to recognize in his suggestions a real step in advance; and consequently I recommend you to prefer articulated to non-articulated tubes. Difficulty in sivallowing is a formidable symptom, to which I long ago di- rected attention, and to which Dr. Archambault attaches special impor- tance. This difficulty arises from fluids passing through the glottis: the result is violent convulsive cough every time the child tries to drink; and the fluids, entering the trachea and bronchi, spurt out in quantity by the canula. Besides the serious consequences arising from the contact of fluid aliment (which is sometimes insoluble, and consequently irritating) with the bronchial mucous membrane, children sometimes feel an insurmount- able disgust at food, and prefer to allow themselves to die from hunger than to eat or drink. This complication has too often been the cause of death after tracheotomy not to stimulate me to use all my efforts to find a means of contending against it. The best plan is to interdict liquid food: I give children very thick food, milk or beef tea thickened with vermicelli to such a consistence as to render it fitter to be eaten with the fork than with the spoon; or I give them hard eggs, well boiled eggs beat up with milk, and underdone butcher-meat: I interdict every kind of fluid. Should excessive thirst, however, exist, I allow pure cold water, taking care that it is given a long time after, or immediately before eating, so as to avoid the excitation of vomiting. It ought, however, to be remarked, that the symptom of which I am speaking rarely begins to show itself till three or four days after the operation, and that it seldom continues later than the tenth day, although in some children I have seen it last much longer. One might suppose that the laryngeal passage, which is thus so very open for the reception of drinks and liquid food, must also be sufficiently open to admit air enough for the purposes of respiration; but such is not the case. It is found, on removing the canula, that the laryngeal aperture is still in- adequate; and even some days later, upon closing the wound with strips of adhesive plaster, the symptoms just described continue with equal violence. It is not very easy to explain these symptoms-this difficulty of swal- lowing. Dr. Archambault believes that the child who has breathed through a canula for some days loses the habit of harmoniously moving the muscles which shut the larynx, and of managing those which propel the alimentary bolus into the oesophagus. He says that he has discovered a remedy for this dysphagia: it is sufficiently ingenious, and consists in closing the canula for an instant with the finger, at the moment when something has to be swallowed: in this way, the child is obliged to open his larynx, and thus, normal harmony of muscular action is re-established. In some cases, this little stratagem is successful, but .generally it is a complete failure. This frequency of failure is explained by what I have already said; for even when the canula is removed and the wound is quite closed, difficulty of deg- lutition continues, although the laryngeal respiration is free and regular: this probably depends upon the muscles of these parts being affected with that paralysis of which I have spoken to you at some length. I have now, gentlemen, laid before you my views on the operation of tracheotomy, and have stated the little precautions which ought to be at- tended to, so that success may be secured. I have once more repeated pre- cepts which I have a hundred times proclaimed during past years. I should, however, leave the subject unfinished, were I to omit speaking to you of the conditions under which the operation ought to be performed. First of all, what is the period of croup most opportune for interfering by operation? In 1834 I wrote, and in 1851 I repeated the statement: "So long as tracheotomy did not prove a reliable resource in my hands, I said TRACHEOTOMY IN DIPHTHERIA. 431 that the operation ought to be delayed as long as possible; but now, when my successful cases are numerous, I say that it ought to be performed as soon as possible."* Modifying that proposition, so as to deprive it of its absolute form, I still maintain that the earlier the operation is performed, the greater are the chances of success. The ingenious experiments of Dr. Faure have indeed demonstrated that when an animal is slowly and methodically asphyxiated, clots form in the heart and large vessels during the latter period of life.f The operation ought, therefore, to be performed before death is imminent; but still, let me add, that to whatever degree asphyxia may have proceeded-though the child should only have minutes to live- tracheotomy ought to be tried: there is a chance of success, provided the local lesion, the croup, constitutes the chief danger of the disease. This limitation is important: for if the diphtheritic poisoning has seri- ously tainted the economy; if the skin and nasal fossae are the seat of the specific inflammation; if a rapid pulse, delirium, and prostration indicate extreme poisoning; if, in a word, we have to do with malignant diphtheria, the chief danger is in the general state of the patient, ami not in the local lesion of the larynx or trachea. The operation must not be attempted in such cases, as in them it is invariably followed by death. The condition which exceeds all the rest in value as a prognostic of suc- cess, as has been admirably expressed by Dr. Millard in his excellent thesis,£ is the predominance of the symptoms of asphyxia over all the patient's other symptoms. "Unfortunately," says he, "it is not always easy to be quite sure amid an aggregate of symptoms, often very complex, what symptoms are dependent upon the physical affection, and what are due to diphtheritic poisoning of the system or to some special complication." We are often obliged to follow the indication which is most urgent, constrained to make the dying child breathe, and do not perceive till after doing so, that there is no chance of recovery: even when we suspect the presence of incipient death, we feel compelled to operate, notwithstanding the almost hopelessness of the case, simply because there is no absolute certainty as to its hopeless nature. "Operations for tracheotomy," continues the same author, whom I take a pleasure in quoting, "performed under such circum- stances are not otherwise objectionable, except in this, that they figure in statistics along with other cases, and so have a tendency to mislead opinion and to discredit one of the greatest triumphs of curative art. The fear of reducing the proportion of successful cases must not, however, too easily induce the physician to desist from operating: he must not assume so grave a responsibility till he has made a minute methodical analysis of all the symptoms, and has detected the existence of an inevitable cause of death. I have on several occasions exercised this right, in cases which would not have borne discussion, and at the autopsy I have never regretted having followed this course: but in every case in which I have had the slightest doubt, however unfavorable the conditions for operating may have been, I have used the bistoury, deeply impressed with the soundness of the maxim -Melius anceps quam nullum." These, gentlemen, are the words of wis- dom, and I most heartily adopt them. Age is still a question which remains to be considered. It is one of chief importance, and requires to be well weighed. I have stated, that in the croup of adults, tracheotomy is less successful than in children. I gave * Journal des Connaissances Medico-Chirurgicales for September, 1834: and Nou- velles Recherches sur laPcriode Extreme du Croup, in the Union Medicale for 1851. f Faure: Archives Generales de M6decine: 5me serie. J Millard (Herman): De la Tracheotomie dans le cas du Croup: Observations recueilles a I'Hopital des Enfants Malades. Paris, 1858. 432 TRACHEOTOMY IN DIPHTHERIA. you as a reason-possibly an incorrect reason-that in adults, from the anatomical disposition of the parts, the passage of the air into the lungs has been left free for a longer period, so that the diphtheria has had time to gain the bronchial tubes and their minute ramifications, before the abso- lute necessity has arisen for having recourse to tracheotomy: but in chil- dren, success is all the more certain, that the child is not very young. This is a fact which has been clearly established by the statistical tables given to elucidate the question of age in the works of Dr. Millard and Dr. Peter. Dr. Peter says: " Both in boys and in girls, tracheotomy was always unsuccessful when performed on very young subjects: thus in 56 girls and 51 boys, on whom tracheotomy was performed during the year 1858 at the Children's Hospital, it was performed 15 times on girls between two and three years of age, and 11 times upon boys between the same ages: in these 26 cases it failed. It was only in children above three years that success- ful cases occurred. Taking as the basis of comparison a very large num- ber of cases of tracheotomy, it was found that the age which gave the largest proportion of recoveries was five years in boys; viz., 7 recoveries in 8 operations; and six years in girls, viz., three recoveries in 4 operations."* Again, to quote Dr. Peter, who, in the work from which I have just quoted thus expresses an opinion in conformity with my own: " Children below two and up to two and a half years of age seem to sink under the influence of traumatic fever, and it is generally during the twenty-four or thirty-six hours which immediately follow the operation that death occurs. Scarcely have two hours elapsed after the operation, when the number of pulsations and respirations increase in a remarkable manner, and the temperature of the skin rises in the same degree: then, little by little, the face becomes red, and there is burning thirst, while the heat of the body is dry and in- tolerable : the child sinks into a slumber, which is occasionally disturbed by some convulsive movements: and then he dies." You are aware that before two years of age croup seldom occurs; but still, as you may meet with cases in children of an earlier age, even in chil- dren at the breast (as has occurred in my own practice), it is essential to bear in mind that at that period of life, there is a very small chance of tracheotomy proving successful. I must tell you, however, that in 1834, I operated on and cured a child thirteen months old ; and with your per- mission I shall now relate the history of this case, which I published in the Journal des Connaissances Medico-Chirurgicales for June, 1834. On the morning of Sunday, 11th May, 1834, Dr. Corsin sent for me to see the child of a carter of Petite-Vilette, by name Pierre Drodlinger. The child was an unweaned boy, thirteen months old. He had had cough for four days: and during the night of Saturday, great oppression of the breathing supervened: the cough in the first instance, completely ceased, and the voice was lost. Under these circumstances, Dr. Corsin was called in, and finding that the patient was already in a desperate state, he re- stricted his treatment to the administration of a draught of tartar emetic and musk: and immediately sent for me. The symptoms of croup were well marked: the suffocative fits were so severe, and followed each other in such close succession, that I made the necessary arrangements for perform- ing tracheotomy. The operation was difficult: at last, after being occupied with it for ten minutes, I opened the trachea ; and just as I did so, a large strip of false * Peter (Michel): Relation d'une Epidemie de Diphtherie, observee & I'Hopital des Enfants en 1858. [Memoire Couronnee par la Faculte en 1859.] TRACHEOTOMY IN DIPHTHERIA. . 433 membrane was spurted out to some distance. I cleared out the trachea and bronchial tubes, injected eight or ten drops of a solution of nitrate of silver, and inserted a canula. The poor child breathed at his ease : with fear he regarded us, and looked about for his mother, who had fled from the house. I sent for her: when she arrived, the little fellow stretched out his arms to her, immediately unfastening her dress and the neckerchief which covered her bosom, set himself to suck with avidity. For three days, the canula was changed evening and morning, and every six hours I introduced some of the solution of nitrate of silver : on the fourth day, this injection was performed for the last time. Every hour, some drops of water were thrown into the trachea, and the canula was mopped out. The introduction of water was continued for ten days. During the first four days after the operation, the child threw off' pellicular masses ; and one of the pellicles expectorated on the second day was of considerable thickness. Fever set in some hours after the operation, and subsided on the third day. On the seventh day, the introduction of a new canula irritated the wound, caused swelling of the edges of the opening, and rekindled high fever. By the ninth day, these symptoms were calmed down : on the tenth day, a great part of the air which entered the lungs, passed through the larynx : on the eleventh day, the canula was removed, and the wound closed. Next day, all the air passed through the larynx. I have had very recently another successful case which I may place in the same category with that now detailed, although the child, being two years old all but six days, was on the very confines of that age within which I said the operation was attended with very little hope of success. This patient was a female child born on the 30th April, 1856 : she was brought to our wards on the 24th April, 1858, having then all the symp- toms of the last stage of croup. There was no trace remaining of pharyn- geal diphtheria : I operated on her, and after the operation, she evacuated strips of false membrane through the artificial opening in the neck. Con- valescence was long and difficult. It was impossible to remove the canula finally till the seventeenth day, although before that date several attempts to do so were made. Diphtheria invaded the wound, and was only got rid of by repeated cauterizations. An attack of distinct small-pox afterwards supervened, but did not impede the progress of the cure ; which was com- plete on the 13th May, when the child was taken from the Hotel-Dieu. This case, that of the child Drodlinger, and the memoir of Dr. Maslieu- rat-Lagemard presented to the Academy of Medicine in 1841, inspired confidence in the value of the operation of tracheotomy in croup irrespec- tive of the age of the patient. Dr. Maslieurat's memoir contained the report of a third successful case of tracheotomy in a very young child-in a child of twenty-three months old. To these cases I now add a fourth, for which we are indebted to Dr. Bell of Edinburgh, who, in 1862, per- formed tracheotomy with success in a child of seven months : also a fifth case, published by Dr. Barthez,* my honorable colleague in the hospitals, the subject of which was a little girl of thirteen months. Great clinical importance belongs to these cases : they stand alone in the records of science, but still they seem to me to justify operative inter- vention, irrespective of the age of the patient, whenever asphyxia threatens life. Possibly, at some future period, we may be able to calculate from statistical data the probability of success from tracheotomy performed on very young children : but even though the chance of success should be found to be small, I should not hesitate to recommend the operation, be-j * Barthez : " Gazette Hebdomadaire," for 19th December, 1862. vol. I.-28 434 THRUSH. cause, when it is well executed, it is not in itself a source of danger, and may often offer the only hope of saving the patient's life. In conclusion, gentlemen, I sum up the whole argument by saying, that whatever be the age of your patients you ought always to give them the chance of being saved by tracheotomy, when there is no special or absolute contraindication. Should the performance of the operation be difficult, in consequence of narrowness of the trachea, from shortness or fatness of the neck, be assured that by operating slowly, and in accordance with my pre- cepts, you will be enabled to surmount all the little obstacles originating in these conditions. LECTURE XXI. THRUSH. Synonyms.-Micro graphists regard it as a Mycelium.-Arises from Modifica- tion of the Secretions produced by Inflammation of the Mouth.-In Adults, is met with in advanced stage of nearly all Chronic Diseases.- Accompanies Intestinal Derangement.-In Children, supervenes also in Diseases, which, regard being had to the Age of the Subject, may be con- sidered Chronic.-Indicates, irrespective of the cause, a general state of Inanition.- When purely Local, is Not a Serious Affection.-Mixed Thrush.-The Mouldy Eruption of Thrush may become developed on any Mucous Membrane covered with Epithelium in which Secretion is Altered.- The Different Erythematous Affections which Accompany it depend upon a General State of the System.- Treatment: The Local Lesion is Easily Destroyed.-Necessary to Continue the Use of Topical Agents for some days after the Disappearance of Thrush to Modify the Inflamed State of the Mucous Membrane.-Same Treatment is Applicable to the Cutaneous Lesions.- When Thrush depends on a General Condi- tion of the System, the Treatment must be directed to the removal of the Causes of that Condition. Gentlemen : A woman, who had been confined a fortnight previously in the Lariboisiere Hospital, was admitted to bed No. 10 of St. Agnes's Ward. She had left that hospital perfectly re-established in health, and came to the Hotel-Dieu with her infant, whom she did not wish to nurse, being in this respect like too many other women. The poor infant was dying from hunger, and in a deplorable, utterly hopeless state. You have seen confluent thrush covering the mucous membrane of the mouth. I avail myself of the opportunity afforded by this case of speaking to you of this disease, which, in pathological treatises, is confounded with plastic affections, though it has but a remote analogy to them. Thrush [mug net, blanchet] is an affection characterized by the presence of small granular masses, which at first are transparent, but soon acquire a dull white color : they are developed on the surface of mucous membranes, particularly on that of the mouth : they generally first show themselves on the tip and edges of the tongue, and at other times on the labial commissure and inside of the lips, as well as on the inside of the cheeks. The millet- seed rash [le millet']-for so the affection is still designated-also appears on the veil of the palate, tonsils, and pharynx. The individual miliary con- THRUSH. 435 cretions, by increasing in number, form irregular patches varying in extent and thickness, of a creamy-white color and caseous consistence, suggesting the idea of a layer of coagulated milk. Sometimes they have a yellowish, and at other times a gray tint, in which latter case there is a possibility of their being mistaken for diphtheritic deposits. Whatever may be the seat and extent of the affection, it is only developed on mucous membranes, which, when in a normal state, are paved with epi- thelium. It is never found in the nasal fossae; and when it invades the pharynx, it stops short at the posterior orifice of these cavities. When it covers the epiglottis, and the aryteno-epiglottidean folds, it never penetrates into the larynx. If it reach the oesophagus, it never proceeds to the intes- tine ; for, as you know, the epithelial pavement of the upper portion of the digestive canal stops at the cardiac orifice of the oesophagus. Thrush was formerly called aphthes confluents, aphthae confluentes, aphthae lactantium, and aphthae infantiles. No names could be more objectionable, for the affection has not the least resemblance to aphthae. In thrush we meet with no vesicles, papules, nor ulcerations, not at least in the first state of the affection ; and the difference between thrush and aphthae is as wide as that between scarlatina and small-pox. The terms muguet and blanchet are much to be preferred to aplithes, for they do not imply any opinion as to the nature of the affection: they refer to the aspect of the lesion which they characterize, an aspect which has been justly compared to a little white flower of powerful perfume, the lily of the valley [muguet] convallaria maialis, which, in May, blossoms in our woods, and which all of you know. Thrush, then, is chiefly an affection of the buccal mucous membrane. It is sometimes a purely local affection, but, at other times, it is the sign of a particular condition of the general system. When infants are obliged to make violent efforts in sucking, from the nipple being too small or not well formed; when they have to suck those linen, leather, or caoutchouc contrivances used by women whose nipples are chapped or too short; or when, being artificially nourished, they have sucked the hard orifices of feeding-bottles, their mouths very soon become the seat of an inflammation which leads to a fibrinous exudation, upon which the sporules of thrush are developed. Till the microscope came to our assistance in the study of pathological lesions, it was believed that the whitish concretions of thrush were entirely composed of'fibrin deposited in very fine layers upon an inflamed mucous membrane, and that the affection was of the plastic character. The micro- scope, however, has demonstrated that the characteristic element of thrush is a cryptogamic plant similar to the sporotricium, according to M. Gruby; or a mycelium, the oidium albicans, according to M. Charles Robin,* con- sequently a mould similar to that which forms on milk, as well as on organic animal and vegetable substances. This is a point regarding which, at the present day, no doubt can exist. It is equally a matter of certainty that, for the development of this mycelium, special conditions are requisite : there must be a pre-existing inflammation of the mucous membrane on which it is seated, and that inflammation must have a somewhat specific character. When there is inflammation of the mucous membrane of the vagina, the mucous secretion resulting therefrom contains animalcules of a particular kind, which are more or less numerous according to the greater or less severity of the inflammation. It does not follow that the inflammation is the result of the presence of the animalcules: it only shows that the muco-purulent secretion, in undergoing alteration, becomes possessed of qualities in virtue * Robin (Charles): Histoire Naturelle des Vegetaux Parasites. Paris, 1853. 436 THRUSH. of which animalcules are developed. Something takes place analogous to that which occurs in milk. When milk is pure it is impossible to discover in it any extraneous animal or vegetable product; but if it be allowed to get sour its constitution becomes modified, and then there is developed in it an infinite number of microscopic animalcules which have their place in the nosological scale. The first condition, then, required for the development of thrush is the presence of a special secretion, and that secretion is necessarily a product of inflammation. Even micrographers do not dispute this fact; for they admit that a fibrinous substance constitutes the greater portion of the granular bodies of thrush, and that the mycelium is a secondary element. Such being the state of the case, it is of very little importance, looking at the question from a clinical point of view, whether thrush be a vegetable parasite originating under certain special conditions, and in accordance with the laws of the so-called spontaneous generation of an inferior order of organized beings ; or whether it is an animal substance composed of fibrin and muco-pus. Is it not, whether we adopt the one theory or the other, a pathological product, originating in a morbid condition of the persons in whom it is found ? Does the settlement of this question affect the aspect of the affection, the nature of the malady, or its symptomatic manifestations ? Assuredly not. Neither does it affect the treatment; for it matters very little to the physician whether he has to do with a mush- room or a false membrane, as experience has put him in possession of sure means of curing the patient: and his highly scientific views upon the mooted point have proved useless to him. Far be it from me, however, gentlemen, to disparage the service which micrographers have rendered to nosology; but on the other hand, it would be wrong to exaggerate the bear- ing and practical utility of their discoveries. Under what conditions does thrush supervene? In the first place, let us see in what circumstances it occurs in adults? It supervenes in all chronic maladies, in pulmonary phthisis, pleurisy, chronic peritonitis, and affec- tions which are generally under the influence of the tubercular diathesis : it supervenes in chronic diarrhoea, which is often related to this same dia- thesis : it supervenes in those cancerous diseases of the stomach and intes- tines which give rise to exhausting intestinal fluxes: it likewise supervenes in persons wasting from profuse and long-continued suppuration. Thrush also develops itself at the close of hectic maladies: it is then a prog- nostic of the very worst character. When chronic maladies have arrived at their last stage, nausea, vomiting, and diarrhoea testify to the existing disturbance of the digestive function : the mucous membrane of the stomach and intestines has then been attacked, and is the seat of morbid modifica- tions : the mucous membrane of the mouth, participating in these anatomi- cal and functional disturbances, becomes subject to an alteration in its secretions, and thus a condition is produced favorable to the development of thrush. The local affection, then, is entirely dependent upon a serious lesion of the digestive apparatus, a lesion too which is itself the sign of a still more serious lesion of the general system. Finally, I repeat the prop- osition, that, however we may explain it, it is a fact that when thrush supervenes at the close of chronic diseases, it is generally a prognostic that dissolution is near. In children, thrush is observed under similar circumstances. In them also, it is in diseases of long duration that it appears: here, however, dura- tion is a term relative to the age of the subjects, for, a disease which lasts eight or ten days is a long disease in one whose age is only fifteen days. It is in infants of a few days old or in children in the first months of their exist- THRUSH. 437 ence, who have been affected for some time with affections of the digestive function or with a disease of the skin or respiratory apparatus, that we find thrush becoming developed. In them, as in the adult, it is the local expression of a very bad state of the whole system. Usually, this bad general condition is the result of improper alimentation, or to speak more correctly, of inanition, which is the final consequence of malnutrition. The defect in diet may possibly be in itself absolute, as I have too often seen; or the infants may be fed with aliment quite unsuited to their diges- tive organs ; as for example, when in place of getting the milk of women, or at least of cows, they are gorged at a very early age with boiled meat, meat broths, and vegetables passed through the cullender, a practice which we see perpetrated by nurses, and even by mothers devoid of intelligence or under the dominion of stupid prejudices. When thus undergoing prem- ature weaning, the poor infants are attacked with gastric and intestinal affections, regarding which, on a future occasion, I shall have to speak to you, and under the influence of which thrush is developed. But the defect in alimentation-in this particular case we must say the malassimilation-may depend upon an original and direct lesion, or on a sympathetic disorder arising during the course or the beginning of some other disease, such as erysipelas or pneumonia; or also in the course of scleremia, that disease peculiar to new-born infants, which is characterized by great debility, and in particular by induration of the skin and cellular tissue of the extremities, extending sometimes to the trunk, and in which oedema and swelling, one or both, may be either present or absent. Thrush, therefore, being the local manifestation of a serious general affec- tion of the system, it ceases to be matter of surprise that so excellent an observer as the late Dr. Valleix asserted that it was so formidable that twenty of every twenty-two patients who had it died from it.* Valleix collected at the Children's Hospital the dismal statistics on which he based this opinion: the subjects observed by him were children abandoned by their mothers, and almost in every case dying from hunger, suffering for the most part from inflammatory affections, generally from affections of the stomach and intestines. Now', in such cases, thrush is the herald of the near approach of death ; but it is the disease during the course of which thrush has supervened, and not the supervening thrush which carries off the patient. Gentlemen, the first form of thrush to which I have referred has no prognostic significance : it is simply a local affection. It has no import in the least degree serious, and remains confined to the parts in which it origi- nally appeared : this is the only form of the affection which those physi- cians have had in view, who have maintained, in opposition to Valleix, that thrush is one of the mildest of maladies. As I stated at the begin- ning of this lecture, when an infant encounters difficulty in sucking, whe- ther that difficulty arise from the nipple of the breast being badly formed, or whether it proceed from sucking a hard teat attached to a feeding-bottle, or an artificial nipple, it is-under an epidemic influence of which we know nothing-seized with inflammation of the mucous membrane of the mouth, in other respects the general health remaining good: this stomatitis forth- with gives rise to thrush, which will generally be very transient, and not troublesome. But should this form of thrush become confluent, if the patches which form are very thick in their substance, and very large, they cause considerable embarrassment in sucking, an embarrassment of which * Valleix: Clinique des Maladies des Enfants Nouveau-nes, chap. iii. Paris, 1838. See also the same author's " Guide du Medecin." 438 THRUSH. the infant gives evidence by making a ceaseless chewing movement with the jaw, and almost incessantly protruding the tongue. This embarrass- ment will be increased by the pain which the infant suffers from the acute inflammation of the tongue and mouth. From the important part which the tongue plays in the action of sucking, you can understand why an infant with an inflamed tongue will refuse to suck: you can also understand that although idiopathic thrush is in itself a mild affection, it may become, under certain circumstances, the starting-point of a formidable disease : by rendering alimentation difficult or perhaps impossible, it may be the indi- rect cause of the patient's death. Such cases, however, are altogether exceptional. I must, therefore, still maintain the proposition that idio- pathic thrush is, strictly speaking, not a disease, but simply a slight and transient local affection. One who understands the right treatment can generally master the affection in twenty-four, thirty-six, or forty-eight hours, or at least in three or four days. Infants very quickly begin to take the breast as before, and return to perfect health, when the transient disorder of the mouth has passed away. There is another kind of thrush which requires to be distinguished from those which I have already described, and to which, if I may, I propose to give the name of mixed thrush [muguet The affection of the mouth in which it originates, and which, in the first instance, was alone present, is simply the earliest manifestation of a general condition under the influence of which it is produced. Symptoms of a more or less serious character connected with the stomach and bowels supervene, showing that mischief exists of so formidable a character, as to lead to a general derange- ment of the whole system in very young children. Indeed, it is not un- common to see new-born infants, who at first seemed only to have stoma- titis along with thrush, very soon afterwards seized with vomiting and diar- rhoea, accompanied by erythema of the buttocks, which I pointed out to you in our little patient who lies in bed No. 16. The state of phlegmasia, or if you prefer the term, the pathological state (for perhaps I am wrong in making use of the term phlegmasia, since inflammation really exists), that pathological condition occupies the entire continuity of the digestive canal from the mouth to the extreme end of the passage. In the mouth, you see the mucous membrane stripped of its epithelium, of a more or less vivid red color, and the sty face of the denuded dermis covered with char- acteristic concretions, distinct on the upper surface of the tongue, and con- fluent (forming caseous patches) upon its under surface and on the inside of the cheeks. On the buttocks, likewise, the skin is of a bright red, and in some places stripped of its epidermis. On the skin and on the mucous membrane, the lesion is the same in kind ; but as there is no secretion from the skin, to cause the development of mycelium, you will there only find a trace of phlegmasia; whereas from the mucous secretion offering condi- tions favorable to the generation of oidium, the mucous membrane of the mouth simultaneously presents the lesions which indicate inflammation, and the production of the peculiar deposit on which the thrush is de- veloped. The child on whose case I am now lecturing is affected with that kind of thrush. It is in him, in point of fact, the first manifestation of a very serious general condition of the system, under the influence of which the inflamma- tion of the mouth has originated. This child does not suck, and although he has still all the appearance of good health, his life is in great jeopardy. From want of proper alimentation the blood, no longer receiving its repara- tive materials, becomes impoverished, and its secretions are necessarily altered in character. The organs, whose function it is to eliminate from the blood THRUSH. 439 the elements of these secretions, must in consequence undergo a special pathological modification possessing all the characters of inflammation. The mucous membrane of the mouth was first attacked, and that of the stomach and intestines will be affected next in turn, although as yet the case seems to be nothing more than thrush, that is to say, nothing more than an unimportant local affection if looked at by itself: the child is never- theless inevitably doomed to die within a very brief interval, unless, with all possible speed, measures be taken to supply it with the nutriment of which it is in need. Here, then, gentlemen, are the three kinds of thrush which ought, in my opinion, to be recognized. First: there is thrush occurring in infants as a purely local affection, depending upon irritation of the mouth, more or less acute in character, and longer or shorter in its duration. It is not accom- panied by any symptoms affecting the general system, nor is it more than an insignificant malady, although, in a few very exceptional cases, it may be the cause of serious mechanical obstacles to due alimentation. Second: there is that kind of thrush which supervenes both in adult and child, as the sequel of a severe attack of disease, appearing as the final manifestation of some serious disorder to which the system has been subjected. Third: there is thrush showing itself as the first manifestation of a severe constitu- tional disorder, the other symptoms of which are not long in following. You can perfectly appreciate the differences which exist between the second species of thrush and that which I call the mixed [mixte] form of the affec- tion. Valleix attached great importance to erythema of the buttocks, which he regarded as present in almost every case, and as one of the earliest observed symptoms of thrush in children. This erythema is more or less extended: sometimes it invades the thighs, the posterior and inner aspects of the legs, the scrotum, and the labia majora: the redness varies between a bright red and a brownish-red. The skin is often excoriated, and, in some rare cases, it becomes scarred with pretty deep ulcerations. The erythematous redness and the ulcerations show themselves likewise on the heels and malleoli. It would, however, be a mistake to consider them as symptoms of thrush. Cutaneous inflammations originate in the same causes as the inflammation of the mouth which gives rise to thrush. The two affections are similar in respect of their cause, but neither of them in any way dominates over the other. In the majority of cases the erythema is the result of the irritation pro- duced in the affected parts by the contact of urine and fecal matter, and the friction of these parts with the swaddling-clothes of the infant: this explains why the erythematous inflammation is met with particularly in the shins and heels, and why it is more decided, and why it more commonly proceeds to inflammation in these parts. They are the parts subjected to the most energetic and constant friction, from the child ceaselessly moving the legs and rubbing his heels against one another, and against the swad- dling-bands in which the malleoli are wrapped. You will see redness of the buttocks and inferior extremities in the healthiest infants, particularly in those, of whom we receive too many in the hospitals, more or less neglected in respect of cleanliness, and swaddled in coarse linen. Erythematous red- ness showing itself independently of thrush may be regarded as a first degree of the erythema which accompanies that affection : it enables us to understand the mechanical causes of the erythema of thrush, though there is this difference, as I have already remarked, that in the erythema of thrush there exists a general cause, as well as one which is local and mechanical. Here the same thing takes place as occurs in persons suffering from putrid 440 THRUSH. fever or any other septic disease. Seeing that an individual who has sus- tained an injury, a fracture of the thigh-bone for example, but who in other respects is in good health, cannot remain on his back for forty-five days without having some redness of the buttocks, it is obvious that much less time will be necessary for a patient with typhoid fever not only to have erythematous redness, but even excoriations and gangrenous ulcerations of greater or less depth over the sacrum, the ischiatic tuberosities, the heels, or any of the bony projections subject to pressure or friction. This arises from the fact that independent of pressure or friction, independent of irri- tation produced by the contact of urine or faeces, there exists deficient vitality of the skin, aiql a remarkable tendency to sphacelus, which is one of the characters of that condition conventionally called putridity in severe fevers, and is one of the consequences of inanition. There is, I repeat, a similar state of matters in the erythema and ulcer- ations of children affected with thrush. There exist, both in the erythema and ulcerations, and in the thrush, manifestations of the bad general state of the individual's system; but the two have not that mutual relation to each other which Valleix wished to establish.* Without dilating more on these questions, I now come to the subject of treatment. When thrush is a purely local affection, it is easily cured ; all that is required is the use of borax-honey. This preparation, according to the formula which I employ, is composed of equal weights of borax and honey- of each 10 grammes [155 grains]. The whole of the interior of the infant's mouth ought to be smeared with this mixture seven or eight times; and if this be done, it will generally be found, at the end of twenty-four or forty- eight hours, that the malady is gone. Possibly, some of the salve may be swallowed by the patient; but from that no great inconvenience can arise, as borax is no more injurious to the economy than bicarbonate of soda ; there may even be an advantage in the occurrence, should the-thrush have reached the lower portions of the pharynx and oesophagus, by the salve there producing a beneficial effect. The topical application which I have now described is in such general use in my wards, that the nurses frequently do not wait for the arrival of the physician to commence the treatment of children brought in with thrush. Consequently, it often happens that in the morning I see little patients, who had been admitted with thrush on the preceding afternoon, who were quite cured of it in a few hours. It is necessary, however, gentlemen, to continue the treatment even after the disappearance of the thrush, because there still remains a necessity to cure the inflammation of the mucous membrane of the mouth, under the influence of which the affection was developed : unless that inflammation is modified, the thrush which went away so quickly will be certain to reap- pear. Chlorate of potash may be substituted for borax, the quantity and the method of employing it being the same. I must say, however, that it has never seemed to me to act so rapidly as borax. Should thrush resist the action of these modifying agents, there remains another to be employed which it never resists; that is nitrate of silver. A weak solution, a solution in the proportion of one gramme of the salt [15| grains] to ten grammes of distilled water, I consider preferable to the solid caustic, because it is easier to touch all the little folds of the buccal mucous membrane with a hair pencil than with a stick of lunar caustic. Perhaps the solution of the nitrate of silver is to this extent objectionable, that if * Valleix: Clinique des Maladies des Enfants Nouveau-nes. Paris, 1838. THRUSH. 441 the child swallowed some of it, nausea or even vomiting might be the con- sequence; but these inconveniences, which after all are not very serious, may be averted by injecting water into the mouth after the use of the solu- tion. In the adult, the blackening of the teeth is an additional drawback to the nitrate of silver. When, therefore, in adults, thrush does not yield to salves, or washes of borax, or chlorate of potash, recourse must be had to cauterizations with solutions of sulphate of zinc or sulphate of copper, in the proportion of ten parts (by weight) of the salt to one of water, the patients being recommended to rinse the mouth and spit immediately after the operation. The local affection is cured! If it had alone existed, nothing more would remain to be done; and the infant would resume taking the breast. But when the local affection is under the dominion of a peculiar state of the system, it will not be long in reappearing, whatever you may do; or at least you will require constantly to repeat the application of the means by which you seek to destroy it. I need hardly say that this end is unattain- able in persons who have phthisis or cancer, or who have arrived at the last stage of an attack of a bad fever, or are the subjects of hectic fever. In infants, when thrush is connected with a bad state of system de- pendent on malnutrition, no time must be lost in providing them with good wet-nurses. In families, mothers very often wish to have the pleasure of suckling their children, even when from delicate health they do not possess the essentia] conditions of a good nurse. Their infants, from sucking empty breasts or only getting very poor milk, soon begin to pine and to become affected with thrush. However much displeasure you may give to a mother to whom to continue the suckling of her infant would be a great delight, do not hesitate to use your authority. It is one of those occasions upon which the physician must speak with imperious authority, so as to bear down all the opposition which his opinions may meet with from the family. Set forth the danger which is being incurred by the patient confided to you, and insist with all your power on the absolute necessity of action being taken in accordance with your demands. Reparative aliment-and woman's milk is the best and most suitable food for infants-may of itself prove sufficient by restoring the infant to health, to prevent the reappearance of the thrush which the topical reme- dies have cured for the time being. If there exist erythema of the but- tocks, or ulceration of the shins and heels, you are then in a position to contend against them advantageously. This may be done by powdering the affected parts with white bismuth. If that fail, employ a mixture of powdered starch and white precipitate. If still the cure progresses slowly, prescribe lotions of eau phagedenique,* and touch the ulcerated points with a weak solution of sulphate of copper. When thrush is connected with disordered digestion in an infant whose feeding is suitable, the treatment must be directed to that disordered diges- tion and the associated gastro-intestinal phlegmasia. On a future occasion, gentlemen, I shall return to this important question; but to-day I may mention that in the treatment of such cases much benefit is obtained from the use of alkaline preparations. Prepared chalk rubbed up with syrup, and given to the infant before sucking five or six times a day, in doses of from 25 to 30 centigrammes [from to grains], and lime-water in doses of from 40 to 60 grammes [about from 1| to 2 fluid oz.], have often, in * The eau phaged&nique is a solution of hydrochlorate of lime, holding suspended binoxide of mercury, which gives it its yellow color. It is prepared by pouring an aqueous solution of eight grains of corrosive sublimate into four ounces of lime- water.-Translator. 442 SPECIFIC ELEMENT IN DISEASE. my practice, rendered real service. White bismuth is also indicated in doses of from 2 to 4 grammes [31 to 62 grains] ; when the powder is thor- oughly mixed up with sugar, children take it easily. It is of paramount importance to regulate the diet, so that the infant may have the breast with as much regularity as possible every two hours. The statistical results published by Valleix are appalling : but you must bear in mind that you will be more fortunate in your private than we are in our hospital practice ; for you will rarely meet with patients so unfavor- ably placed as the wretched children who from the very nature of things come to die in our establishments. Exhausted by the misery and pro- tracted starvation to which they have been subjected by the persons who abandon them, they sink, notwithstanding all the attentions by which they are surrounded. In such cases, the non-success of treatment must not be imputed to the want of skill in the physicians, but to the deplorable hygi- enical conditions to which the patients have been subjected. LECTURE XXII. SPECIFIC ELEMENT IN DISEASE. The Specific Element is Dominant throughout the whole of Medicine.-Dicho- tomic Doctrines of Brown and Broussais.-Diseases have Certain Char- acters in Common, and also Individual or Specific Characters.-Specific Causes.-Specific Symptoms.-Knowledge of Specific Character applied to Diagnosis, Prognosis, and Treatment. Gentlemen : The eruptive fevers are the most typical examples of specific diseases. Before proceeding any farther in the study of the cases which we are observing together, I wish to pause for a little to examine the subject of specific character in disease. I hope to be able to show you that this important question is dominant throughout the whole of pathology and therapeutics-in fact, throughout the whole of medicine. I have al- ready, in former lectures, had opportunities of bringing this subject under your notice. In practice, you will find it confronting you at every step; and as not a day will pass without your hearing me refer to it at the bed- sides of the patients, I must endeavor to give you as complete an idea as possible of that which is understood by the term specific, when applied to diseases. Though we are in the habit of saying that we have emancipated our- selves from the yoke imposed by the doctrines of Brown and of Broussais, we really are still under their influence : although we repudiate them, they are re-echoed in our medical speculations, and in the very language we employ. It, therefore, becomes necessary for me to recall to your recollec- tion the errors which are embraced in these doctrines. However much the two doctrines may be opposed to each other, they rest on a common basis; for although Broussais was the great antagonist of Brown, he never- theless derived the principles of his physiology from the pathological sys- tem of the Scottish reformer, whose incitability differed in an abstract man- ner only from the irritability of Broussais. SPECIFIC ELEMENT IN DISEASE. 443 Brown said that life was maintained by incitants: Broussais said that it was maintained by stimulants. ■ Their physiological theory was founded on this assumption ; and on it likewise was based their pathological hypothesis. In point of fact, they both held that there was only one morbid cause, the excessive or unreason- able use of incitants or stimulants. Difference in the intensity of the cause, and difference in the mode of the reaction of the economy are, they said, the sources of the innumerable diversities of form presented by diseases. This is their common starting-point; for here "incitants" and "stimulants" are two absolutely synonymous words. Brown said,* and Broussais repeated in other terms, that light is the natural incitant, or, what comes to the same thing, the natural stimulant of the eye, the incitation of that organ being vision ; that food is the natu- ral incitant of the stomach, the result of the incitation of which is diges- tion ; that the assimilated materials, the nutritive juices, are the natural incitants of different organs, whence we have nutrition; that the blood is the natural incitant of the organs of secretion, whence, for example, when the kidneys are concerned, we have the urinary secretion, and when the seminal glands are concerned, the spermatic secretion. While Brown and Broussais held that the cause was always the same, varying only in degree, they could not avoid admitting the existence of a modifying influence in the structure of individual organs, in virtue of which the effects of stimu- lation are different. Their assertion that everything was dependent upon the quantity of the stimulus, and that there was an identity in the condi- tion of organs in all persons, was a denial of evident facts. Upon their hypothesis, how can diversity of effects, that is diversity of functions, be explained ? Does not their hypothesis involve prodigious absurdities, ab- surdities quite as great as that which Recamier, a man of undoubted talent, was led into-to the effect, that by exalting the incitability of the nerves of the finger or epigastric region, to a degree of incitability equal to that of the retina, we could see with the finger or the stomach, on adapting to them an optical apparatus similar to the eye? Brown and Broussais, then, were obliged to admit that there exists diversity in the manifestations of vital power due to the special anatomical properties of tissues and organs, of solids and liquids, as well as diversity in the functions therewith connected : but they did not take them into account. The fundamental idea of their doctrines is identical: this Broussais has rec- ognized by adopting as the test of his own doctrine the synthetic proposition of Brown, that all diseases are sthenic or asthenic, that is, dependent either upon excess or deficiency of excitement; but by the manner in which he interprets the effects of reaction, he completely diverges from the path of his predecessor, and arrives at therapeutical conclusions entirely opposed to those of the disciples of Cullen. Brown maintained that all parts of the body are endowed with a particu- lar special aptitude, which he called incitability. This incitability he said was manifested by incitation, and this incitation could only be the result of an inciting force : but this aptitude is limited. Since whenever it is brought into play, it becomes by that very circumstance exhausted, so it requires to be constantly renewed by augmentation of the quantity of the force by nutrition ; or by an accumulation of force taking place through non-expen- diture consequent upon repose of the organism. Thus, by movement, the incitability of muscles is exhausted, and when muscular action has been excessive in degree or too prolonged, the individual, being in the last stage * Brown (John, M.D.) : Elements of Medicine. London, 1795. 444 SPECIFIC ELEMENT IN DISEASE. of fatigue, loses the power of moving. Thus, gentlemen, you perceive how both the pathological and therapeutical doctrine of Brown wholly originates in this fundamental fact. According to Brown every disease depends either upon diminished inci- tability, the consequence of excessive incitation, or an increased incitability the effect of a diminution of incitation. In both cases the final result is debility; and, consequently, the part of the physician ought always to be restricted, first, to the restoration of the vital powers by very moderate stimulants, and, in the second place, to the use of means capable of aug- menting the incitability. Broussais, taking an isolated view of the irritability which exists in tis- sues, held that all diseases spring from the untimely or excessive action of agents having the power of exciting that irritability. According to his view, therefore, the only morbific causes are irritants, and the effects which they produce is irritation. Holding the opposite of Brown's opinion, he thought that it was necessary to restore the functions to their physiological condition, and to endeavor to calm and remove the irritation. Whether the pathological state consists, according to the Edinburgh doc- trine, in a greater or less degree of incitability, or according to the Val-de- Grace theory in an excess or more rarely in diminished irritability, in these dichotomic symptoms (essentially opposed to each other, though having one and the same origin), the quantity only, and in no way the quality, of the morbific cause is taken into account. Treatment of disease based on such systems must necessarily possess extreme simplicity. Brown confined him- self to the use of the class of remedies known as excitants, using in some very rare cases antisthenics, if I may be allowed to use such a term; while Broussais always employed antiphlogistic medicines, except when, under very exceptional circumstances, he prescribed excitants. There is no denying that a certain class of acute inflammations are pretty exactly comprehended within the description applicable to the system of Broussais; for that which renders an inflammatory disease more or less serious is, on the one hand, the greater or less intensity of the cause under the influence of which it has been developed, and, on the other, the differ- ence of the organizations which are affected. But there is another class of diseases which has not this dichotomy: it is the class of specific diseases. It mattered very little to Brown whether small-pox was a specific disease. All he required was to ascertain whether the malady was sthenic or asthenic to enable him to formulate the therapeutic indication of stimulating or lower- ing. It mattered very little to Broussais whether cholera differed in form from dothinenteria ; in both diseases he saw irritation of the digestive canal setting up different symptoms, but the irritation was to him the dominant fact which constituted the necessity for antiphlogistic treatment. Thus it was that the whole of nosology and therapeutics became a tabula rasa. Matters were in this state at the beginning of the century. The doc- trine of Broussais, on first acquaintance seductive from its simplicity, had obtained many adherents when Laennec and Bretonneau, each from his own point of attack, dealt a blow at it, the formidable character of which Brous- sais tried in vain to conceal. Laennec, under the modest title of a semio- logical discovery, and seeming to confine his observations to the study of the diseases of the respiratory organs, wrote a very striking chapter ou nosology. While Bretonneau was restoring the history of acute, Laenne restored the history of chronic diseases. The illustrious physician of Tours overthrew to its very foundations the great edifice of physiologism and pretended rationalism in therapeutics, and on its ruins raised the doctrine of the existence of a specific element in dis- SPECIFIC ELEMENT IN DISEASE. 445 ease. This he did, by calling attention to the elementary fact, that differ- ences in the nature of the cause impart to diseases much greater differences than those which they derive from greater or less intensity of the cause, or from diversity of organization.* In physiology, Bretonneau attributed to the special properties of differ- ent tissues and different organs a much greater importance than that which he accords to the agencies which modify the organism: in pathology, he admitted that a great number of diseases have a common element generally called irritation or inflammation ; but he did not accord to this common element the importance assigned to it by Broussais. Undoubtedly furun- culus, malignant pustule, syphilitic chancre, herpes preputialis, gastric disturbance and dothinenteria have, as an element in common, inflamma- tion characterized by fluxion, by redness appreciable when the inflamed parts are within view, by pain, and by increased temperature ; but along with this common element, there are other elements of great importance which distinguish the different affections from each other, and have a sig- nificance altogether peculiar. The natural history of disease has some remarkable analogies with the natural history of plants and animals. This truth was long ago enunciated by Sydenham, when, in one of the chapters of the seeond section of his Medical Observations, he says, in speaking of pestilential fever and the plague of armies which committed ravages in 1665-1666 : " Unaqueeque morborum non minus quam animalium ant vegetabilium species, affectiones sibi proprias perpetuas ac pariter univocas ab essentia sua promanantes sortita est." Examples in illustration taken from Botany and Zoology will facilitate the understanding of the subject of which I am now treating. Different kinds of vegetables, for instance, present us with characters in common, in virtue of which we place them in the same natural families ; and these common characters are also found in some proximate families; but in the .form of the flower, in the shape of the fruit, in the juices secreted by the plant, there are distinctions which not only prevent families being mistaken for one another, but also prevent the most similar species from being confounded. Thus, dulcamara, datura stramonium, celandine, poppy, the wild brier, and cherry-laurel possess characters in common, but they have each well-marked special characters which make it impossible for the botanist to mistake any one of them for the other. When you study two individuals of the class reptilia and the order ophidia, the ring-snake and the viper, you notice similitudes in their external forms and anatomical structure, but you bestow special attention upon their specific distinctions. The presence or absence of scales or plates on the head of the animal, the presence or absence of poison-fangs, establish for you fundamental differences between two individuals similar in their general appearance; and you could not commit such an error as to regard the viper as a variety of the ring-snake. Well, then, gentlemen, in diseases which seem to bear the strongest resemblance to one another, there are specific characters quite as distinc- tive as those which distinguish the different species of the same family of plants, or the different species of the same class of animals. Now this is what Broussais was not inclined to admit. The inflammation-element, the existence of which we cannot deny, was, to his mind, the chief and indeed the only dominant fact. It is so in some cases: in a purely inflammatory disease, the quantity of the morbific cause is everything, provided allow- * Bretonneau: Recherches sur 1'Inflammation Speciale du Tissu Muqueux et en particulier sur la Diphtherite Paris, 1826. 446 SPECIFIC ELEMENT IN DISEASE. ance be made for diversity of organs and variety of organization: gener- ally speaking, in the phlegmasiae, as in the pyrexise, as well as in the majority of diseases, we have to consider the quantity less than the quality of the morbific cause. Let me use as my illustrations facts which admit of being stated with absolute precision, and are consequently facts the least likely to be disputed. A small vesicle appearing at the base of the glans penis after impure intercourse is certainly in appearance a thing of trivial importance: if judged only by its appearance, it is a much less serious affection than a group of vesicles of herpes preputialis, which is liable to appear under similar circumstances. In fact, if the inflammation-element only be taken into account, the herpetic is the more formidable of the two affections. But how vast the difference, when we proceed beyond that element which they have in common! While the herpetic vesicle, if left to itself, becomes filled with pus, dries up, and leaves in its place, after the formation and fall of a crust, an insignificant cicatrix, the syphilitic vesicle runs, rapidly perhaps, through its stages; but in the place it occupied, you will soon observe an induration of the subjacent cellular tissue, which you will at once recognize as establishing a distinction between the syphilitic and non- syphilitic affection-a distinction which you will consider as of the very highest importance. In this you will assuredly be right; for after recovery from the herpes, you need have no anxiety regarding your patient: when the local malady has disappeared, a radical cure has taken place. Is it so after the cicatrization of the chancre? No! for after two or three months, and sometimes after a longer interval, manifestations will appear on the skin and mucous membranes, which you will connect with the previous existence of the little insignificant-looking vesicle. You will see appear a special cutaneous eruption and ulcerations of the throat; or, if energetic medical treatment does not prevent it, you will have the successive development of other affections originating in the first-affec- tions of the cellular tissue, tubercles on the skin, condylomata, diseases of the bones, such as ostalgia, caries, and necrosis-which if not checked in their progress will lead to terrible disorders. In addition, therefore, to the characters which the syphilitic chancre had in common with the herpetic vesicle, it had specific characters deserving great consideration. The clinical study of diseases furnishes innumerable examples similar to that now adduced: what I have said of syphilitic chancre, I might repeat in substance of a host of other affections. A small pimple forms on the hand of a butcher who has been skinning a sheep which has died of malignant pustule [sang de rate}. It occasions only a disagreeable feeling of tickling in the part: in comparison with a boil, which is often exceedingly painful, it appears to be scarcely deserving of notice. But by and by this pimple, so insignificant and apparently so mild in its character, begins to enlarge : a small slough forms in the situa- tion which was occupied by the pimple: an erysipelato-oedematous tume- faction, commencing in the affected part, gradually invades the whole member: the lymphatic glands of the arm and axilla become engorged: at the same time, fever sets in, which increases from day to day: then delir- ium supervenes: and at last, sooner or later, the individual dies, in a state of extreme debility, with aggravated typhoid symptoms. The little pimple was a malignant pustule. The boil, on the other hand, which almost from the very first caused violent pain, and in which the inflammation-element attained a much more intense degree than in the case of the malignant pustule, gets well spontaneously: the patient, who has suffered a great deal of pain has nothing to fear. The inflammation, therefore, did not play a SPECIFIC ELEMENT IN DISEASE. 447 very important part: the quantity of that element was of no consequence- its quality was everything. The characters which put their special seal on specific diseases are univ- ocal and constantly met with, irrespective of the degree in which exists the common element with which they are associated. Thus, small-pox, whether distinct or confluent, benignant or malignant, normal or modified, will always be found to have its pustules, its own special pustules, which constitute its character, a character as essentially invariable and as specific as the distinctive marks of the natural families of plants, or the natural division of the classes of animals. That which is true in human, is equally true in comparative pathology. Thus, you will see tag-sore [clavelee] that eruptive disease of sheep regard- ing which I spoke in a previous lecture [vol. i, p. 90], comparing it with small-pox in the human subject, show itself by an eruption presenting char- acters perfectly precise and univocal, which enables it to be distinguished from all the other eruptive diseases of sheep. Even plants, so much inferior to animals in the scale of organization, exhibit in their pathological disorders the influence of the quality of the cause, by the form of the disease. The insects which wound the leaves or stems of plants excite at the point of contact the growth of morbid ex- crescences, the univocal character of which points out the agent by which the wound was made. On plants the same kind of scurf always follows the wound inflicted by the same kind of insect; and this occurs with such constancy, that the experienced naturalist can always determine from the form, color, and volume of the excrescence the kind of insect to which the contained larvae belong. Exactly the same thing occurs in respect of an internal or external in- flammation of the human subject. In dothinenteria, there is, in addition to the characters possessed by it in common with all other intestinal phleg- masise, an inflammation occupying a circumscribed locality-a locality which is limited, determinate, and always the same: there is the furuncu- lar eruption of the agminate and solitary glands, and as this furuncular eruption is always found in dothinenteria, it is .very properly regarded as the specific character, the special anatomical manifestation of the disease. In dystentery, which is in reality a form of colitis, special characters are also found : they exist in the intestinal secretions, in the symptoms, and in the anatomical lesions, enabling us to distinguish this form of inflammation of the large intestine from other species of colitis, and to establish the specific character of the disease. Let me remark, gentlemen, that the specific characters of which I have been speaking must not be confounded with the characters which consti- tute mere varieties: in nosology, as well as in natural history, it is neces- sary to keep the two distinct from one another. To continue my comparisons: there is a great difference between the lady's pocket-dog and the large dog [mofosse] of the Pyrenees: still, the two do not belong to different species, but are merely varieties of the same species of the genus cants. The same instincts, the same anatomical and physiological characters are invariably found present in both. Ingenious breeders, by skilful crossing, can produce animals very different from the parent stock, can produce breeds in which the wool, the fat, or the muscle predominates according to the use for which the animal is destined; yet these different breeds are merely varieties of one type, all of which preserve the typical specific characters. So it is also in plants; you know how com- pletely we have it in our power to multiply varieties of a vegetable species, and, so to speak, to create monstrosities. Thus, from the simple pink, a 448 SPECIFIC ELEMENT IN DISEASE. skilful horticulturist produces innumerable varieties, just as from the wild brier he obtains the beautiful roses which adorn our gardens. But both in the animal and vegetable kingdoms, w7e only produce va- rieties-different forms of the same species-and we have no power com- pletely to change the characters of species, far less to create new species. It is long since the horse and the ass have been crossed : stallions have been coupled with female asses, and male asses have been coupled with mares: mules have been the only resulting progeny-that is to say, varieties par- taking of the characters of both species of the genus equiu;, accidental varieties, however, which are not reproduced, and which do not perpetuate themselves. In nosology, no more than in natural history, ought variety of type to be taken for difference in species. Varioloid, or modified small-pox, is not a different species of small-pox, but merely a modification or variety: varicella or chicken-pox is an entirely distinct species. Gentlemen, I insist on this point because some are disposed to see in the specific character of diseases only a question of more or less, while in re- ality, there is as absolute a difference between different species in nosology as in botany or zoology. Do what you will, you will never succeed in transforming roseola into measles, chicken-pox into small-pox, or simple catarrhal bronchitis into hooping-cough. All these diseases have their ab- solute and invariable specific character sharply distinguishing them from one another, whatever may be the degree of their severity. The existence of specific character is so indisputable, and is everywhere so clearly indi- cated, that it is not necessary for the recognition of a nosological species to have before us an assemblage of all the symptoms: as is seen in " de- faced scarlatina " [scarlatine fruste], a single word will often be sufficient to enable the physician to recompose the entire pathological phrase, just as Cuvier recomposed lost species of animals by the study of a few fragments of antediluvian skeletons. Specific diseases derive their invariable characters not from the quantity, but from the quality of the morbific cause: this is invariable in its nature, whatever may be the influence under which it is developed. The class of special diseases is so vast as to fill the greater part of the nosological table. If we study the different causes of diseases, whether these causes are irritants, or agents of an entirely different kind, we shall see results produced which are so invariably characterized by the same forms, according to the nature of the causes, that it will be impossible not to recognize the specific element at every step as we proceed in our obser- vation of patients. A blister on the skin differs in its character according to the cause in which it originates; according, for example, to its being the result of the application of cantharides, of a sunburn, of erysipelas, or of cauterization with ammonia. You know how smarting is the pain of a sunburn : it is not the same kind of pain which is caused by blistering with cantharides or ammonia-it is more acute and lasts longer; but nevertheless, the cu- taneous inflammation caused by blistering with either substance is much more intense than that which results from a burn by the sun : each cause produces its own special effect. Let me illustrate the subject by facts still simpler-by the effects of chem- ical agents, which are very easily ascertained. Each of these agents, when applied to the human body, has, according to its individual nature, its own special action. The pain produced by hydrochloric acid is much more transient than that occasioned by nitric acid; and nitric acid, although it occasions sloughing of the parts which it touches, causes less acute and less SPECIFIC ELEMENT IN DISEASE. 449 persistent pain than cauterization with sulphuric acid, although the destruc- tion of tissues may be less extensive. Every medical student knows that the-application of potassa fusa and the alkaline caustics is much less pain- ful than the application of the chloride of zinc, chloride of antimony, or, arsenical preparations. To sum up in a few words all that there is to say on the subject: the different chemical agents produce so distinctive an action that even a person of little experience can declare the substance which has been used from observation of the effects produced. In these cases, one cannot argue from the quantity of the cause, for experience has shown that it is impossible to produce similar effects with caustic potash and chloride of antimony, whatever proportions of these agents may be em- ployed. That this depends on their respective chemical properties, and on the manner in which the agents combine with the tissues, I admit; but that does not signify, if there be a difference, and if that difference be constant. Let us now examine the action of poisons. All poisons have their own peculiar mode of action, and so characteristic is it that nearly always the slightest examination of the symptoms suffices to determine the nature of the poison. There is certainly no one at all acquainted with toxicology who cannot distinguish by the symptoms poisoning by opium from poison- ing by stramonium, veratria, or strychnia ; or who is unable to discriminate the differences in the consequences of absorption of the venom of the rattle- snake, the viper, the scorpion, the tarantula, the bee, or the mad dog. To every specific morbid cause, the organism responds by the manifesta- tion of effects having a specific character. A man comes into hospital with paralysis of the extensor muscles: the edges of his gums have a bluish fringe: his skin has a somewhat jaundiced hue: he complains of violent colic, and of shooting pains in the course of the nerves of the limbs: in such a case a prolonged examination is not re- quired to diagnose poisoning by lead. The nature of the case is so palpable that one cannot entertain the idea of its being the subject of any doubt. The disease has characters so essentially specific that it is recognized at a glance, just as a tree is recognized at first sight by its leaves and general appearance. You can at once lay hold of the distinctive characters of poisoning with lead and copper, just as you can distinguish at the first glance the different species of the animal and vegetable kingdom. Another patient comes into hospital affected with general tremors: his gums are ulcerated and bleeding, and the teeth shake in their sockets: his mind is enfeebled. Our first question is asked to ascertain whether he is a looking-glass manufacturer, a gilder on metals, or engaged in any other occupation in which mercury is employed : we have at once suspected mer- curial poisoning. There was, in fact, something so characteristic in the symptoms that we could not mistake them. You are acquainted, gentlemen, with the symptoms which characterize the disease produced in the workers in vulcanized caoutchouc factories by inhaling the vapors of sulphuret of carbon. The interesting inquiry of my colleague Dr. Delpech has recently directed attention to this species of poi- soning.* This sagacious observer, by marking with care the specific character of the phenomena in the case of a workman in a caoutchouc factory, phenom- ena which could not be attributed to any known disease, was able to estab- * Delpech (A.): Memoire sur les Accidents que developpe chez les Ouvriers en Caouchouc ('inhalation du Sulfure de Carbone en vapeur. Paris, 1856. Nouvelles Recherches sur 1'Intoxication Speciale que determine le Sulfure de Car- bone. [Annalen d'Hygiine Publique, 1863; 2e Serie, t. xix.] vol. i.-29 450 SPECIFIC ELEMENT IN DISEASE. lish the existence of a new disease, of which he has since met with a certain number of cases, all of them presenting the same characteristic symptoms. The symptoms of this new disease are-disturbance of the mental faculties, .particularly loss of memory; headache, which is more or less acute, and is sometimes very intense; vertigo, occasionally in an extreme degree; pains in the limbs, accompanied by a sensation of general formication and anal- gesia, and, in very exceptional cases, with cutaneous hyperaesthesia; im- paired power of the organs of sense and reproduction ; disturbance of the motor powers, characterized at first by cramps and then by muscular con- tractions ; muscular debility, appearing first in the inferior and then in the superior extremities; finally, anorexia and vomiting. Under the influence of these symptoms the patient falls into a state of more or less profound cachexia. An important character of the disease is the tendency of the symptoms to diminish in severity, and to disappear entirely after a suffi- ciently long removal from the cause which produced them. Since, twenty years ago, chemical replaced sulphuric and chlorinated matches, physicians have had too many opportunities of studying, in the workmen who make these articles, affections caused by phosphorus, affec- tions consisting in necrosis and caries of the maxillary bones, and having this peculiar feature, that they are invariably localized in these bones, and never show themselves in any other part of the skeleton. The lesions of the bones, then, which result from poisoning with phosphorus, have char- acters altogether peculiar and specific. Gentlemen, in the specific diseases produced by physical or chemical agents to which I have now directed your attention, we can lay hold of and see the morbific cause; we can also lay hold of it, as it were, in virulent and poison-diseases. We know that morbid poisons exist in fluids secreted by persons laboring under diseases: the virus of rabies exists in the saliva of the mad dog, and the virus of small-pox in the pustule, although the fluids containing these poisons are identically similar in appearance to the fluids which produce no specific effects. We know that a morbific cause exists in particular secretions of certain plants and animals; for example, in the venom secreted by the gland placed at the base of the hooded dart of the rattlesnake, and in the juice secreted by the glands at the base of the hairs of the stinging nettle. Though in the majority of diseases we cannot thus, as it were, lay our hands on the morbific cause, we are never- theless entitled, as in natural history, to admit its existence. If we found a plant for the first time in a certain district, a plant till then unknown in that district, and if we afterwards found in the same locality a great number of plants all presenting precisely the same characters, we should be entitled to affirm that they all proceeded from one identical seed, although we had not actually seen that primitive seed. No comparison could in myopinion be better chosen, for nosological have, very properly, been likened to vege- table species : the living body has been considered as a field, in which, under certain conditions inherent in the body, morbific seeds germinate, which spring up with their specific characters, reproducing the species, like the seeds of different species of plants confided to congenial soil. This com- parison is perhaps more applicable to inoculable contagious diseases than to others, for of them we may with strict propriety say that the seed is sown and the original reproduced ; but it also applies to infectious diseases. When we see infectious diseases always characterized by similar symptoms, we are led to recognize the existence of special causes to account for the special effects, although we cannot actually lay hold of these causes; just as, in the illustration I have already employed, we are constrained to admit that all the plants came from the same seed. SPECIFIC ELEMENT IN DISEASE. 451 Thus, gentlemen, we all believe in the existence of what are called mias- mata, although we can only form an opinion of them by their effects: we admit that there are several species of miasmata, because there are cor- responding phenomena, peculiar, special, and invariable, which characterize the diseases which we suppose originate in them. Could any of you mis- take marsh fever, which is generally characterized by intermittent par- oxysms, varying in type, and sometimes by neuralgic affections? Could any of you, seeing such a case, fail to conclude that the patient had been exposed to marsh emanations? But here, although the morbific cause elude observation, we are at least acquainted with the conditions under which it has been developed. It often happens, however, that these conditions are not known ; and yet circum- stances convince us that a special cause exists in which originate the special effects which we observe. We are not acquainted with the meteorological and terrestrial conditions under which cholera occurs, and our ignorance as to the. cause of that dis- ease is still greater; nevertheless, no one seeing the disease invariably manifesting the same phenomena, will deny that it has a specific character. We are not acquainted with the cause of dothinenteria, but yet its specific character is admitted by every physician who sees it constantly presenting the same symptoms during life, and the same special anatomical lesions after death : these specific characters are so precise and predominant that confusion is impossible. Every one can distinguish dothinenteric from simple enteritis, when he has before him the anatomical lesions; and during life also, the symptoms enable the one to be diagnosed from the other. To sum up, gentlemen, the remarks which I have now made: we must consider that in every disease there is a common element which may be termed the physiological element-inflammation, irritation, &c.; and like- wise that which may be termed the nosological element, imprinting itself upon the former, giving to the whole disease a special character, and assign- ing to it a unity of origin, a special principle, a nature more or less deter- mined, and, in a word, constituting a morbid species. The common element predominates in diseases which are accidental: a burn produced by fire is an absolute type of this class. Here, quantity of morbific cause is everything, allowance being made for difference of organs and diversity of organization. Although in a great number of diseases, the nosological element dominates over the common element, it would be as absurd to exclude quantity of morbific cause from all participation in the production of effects, as it would be not to take into account diversity of organs and variety of organization : but quantity of cause, diversity of organs, and variety of organization, are here all dominated by quality of cause, and, therefore, we require chiefly to consider the nature of that quality. In certain cases, we can lay hold of the special cause, and, almost at will, produce the effects which are its natural consequences. So it is, in respect of the special phlegmasise produced by special physical and chemical agents, the diseases originating in a virus, in the poison of venomous creatures, or in the absorption of any poison: so it is also, in respect of certain diseases with the causes of which we are not acquainted, but with the conditions under which the causes act we are familiar, as for example, in marsh fevers. In these cases, the existence of a specific cause cannot be disputed : and it is not less present in other diseases in which the causes, as well as the con- ditions under which the causes act, elude our observation: the specific cause is established quite as well by the invariability of the symptoms and forms of the affection, as if we were also equally cognizant of the effects and the 452 SPECIFIC ELEMENT IN DISEASE. causes: from the constancy of the one, it is logical to infer the constancy of the other. Gentlemen, perhaps some of you may think that I have already spoken at too great length upon the subject of the specific element in disease; and may be of opinion that its discussion would be more appropriate in a course on general pathology than in my clinical lectures. I have not, however, been at all afraid of going out of my province in thus discoursing to you, for though it be perfectly true that the subject belongs to the domain of pathology, it is equally certain, as I have already remarked, that it meets us every moment at the patient's bedside, inasmuch as it is dominant throughout the whole of practical medicine. Its clinical importance ap- pears <to me to be so great, that I desire still to make some additional re- marks upon it, with a view to show you how useful, nay how necessary for diagnosis, prognosis, and treatment it is, to understand the specific element of diseases. By placing before you additional details, I shall show you that a knowledge of the specific element in disease is the key of medicine, with- out which it is impossible to proceed successfully in the practice of our art. To deny the existence of nosological species, or, in other words, not to take into account the quality of the morbific cause, and to consider only its quantity, to subordinate the nosological to the physiological element, is to maintain the uselessness of every differential diagnostic except that which is limited to the determination of the state of the organ affected, and the extent of the affection; since the nature of the disease, varying only in degree without changing its species, is necessarily known. To push the argument to its ultimate consequences: what advantage is there in seeking to distinguish small-pox from measles, if the pustular erup- tion which characterizes the former is only a degree of inflammation of the skin more advanced than the exanthem which characterizes the latter? The partisans of the dichotomic schools-if any such persons exist in the present day-would refuse to push the doctrine as far as this. When such persons have to do with diseases manifesting themselves by cutaneous erup- tions, their first anxiety is to discover whether they have a case of small- pox, roseola, measles, or scarlatina: in spite of themselves, they admit the specific element, for their diagnosis is based on the specific characters of the eruptions. If all accept this principle in respect of diseases, the anatomical mani- festations of which appear on the skin, I ask, why was it necessary for Bretonneau and his pupils, physicians and surgeons, to use such great exer- tions to generalize and apply to other diseases, the doctrine of specific causes? Why, I ask, in the different phlegmasise, in those for example affecting the mucous membranes, has there been so obstinate a determina- tion to see inflammations identical in their nature, and varying only in seat and degree? Thus, according to the system which I am now combating, dothinenteria and dysentery are both forms of enteritis, as are' also intestinal catarrh, colitis, and other inflammatory affections of the intestines produced by the action of sulphuric acid, arsenic, croton oil, or any other irritant poison. The anatomical characters of these diseases is essentially different; and do what you will, you will never be able to produce by means of sulphuric acid the lesions produced by arscnious acid, or croton oil; and still more obvious is it, that by none of these agents could you produce the lesions of dothinenteria. In respect of the other characters, the existence of the specific element is still more conspicuous. Dysentery and colitis possess a similitude in kind: both are ulcerative inflammations of the large intestine; but still they have characters so distinctive that it is impossible to mistake SPECIFIC ELEMENT IN DISEASE. 453 the one for the other. I shall have occasion to point out their respective characters during the course of these lectures. The same remarks are applicable to affections of the respiratory organs. In the simplest catarrh, in hooping-cough, and in asthma, the dichotomists see only bronchial phlegmasia, and do not stop to consider the individual peculiarities by which they are distinguished from one another. When I come to speak to you of these different diseases, I shall take care to describe their characters; but, for the present, let it suffice to say, that it is of the utmost importance to be acquainted with them, so as to be able to avoid confounding simple enteritis with follicular enteritis or dothinenteria, or hooping-cough and asthma with simple bronchitis. The importance of this kind of knowledge is very great in relation both to prognosis and treatment. I have already called your attention to this point when speaking of dothinenteric catarrh of the intestinal canal. I then told you that that affection was one of great danger; that the progress of simple enteritis and dothinenteric enteritis was quite different; and that when the practitioner is not acquainted with the natural course of each species, he cannot form a correct prognosis. Take another example. A patient comes with sore throat: he states that on the previous evening, con- sequent on a chill, he was seized with general discomfort, pains in the back and limbs, rigors, loss of appetite, and fever. Next day he complains of difficulty of deglutition, and there is swelling, but only slight swelling, of the submaxillary glands. Upon examination of the pharynx, it is found that there is swelling of the tonsils, with redness of the pillars of the veil of the palate, and that a secretion having exactly the appearance of false membrane covers the affected surface. Let us suppose that you were sent for at the same time to see another patient also affected with plastic sore throat, but in whom there was a different development of the disease. With- out any appreciable cause, he had experienced for some days general un- easiness accompanied by fever: the sore throat was much less painful in this patient than in the other. If you only take into account the anatomi- cal element common to both cases, the resemblance between the two is com- plete. The scalpel, the microscope, and chemical analysis will all demon- strate that in both cases the false membranes are identically the same: to judge from appearances, the last-mentioned patient seems the least unwell of the two. But if you allow the diseases of both to run their course with- out interference, you will see that the malady which set in with the greatest violence and most acute pain, and was accompanied by a degree of fever absent in the second case-you will see, I say, the acute sore throat get quite well spontaneously and quickly, leaving no trace behind; while the other may carry off' the patient with symptoms of general poisoning, or by suffocation consequent upon the development of pseudo-membranous laryn- gitis or croup. In both cases, however, there was plastic sore throat; but with this difference, that in the one case the malady was common membra- nous sore throat, that is to say, herpes of the pharynx, which is seldom a serious disease, while the other was malignant membranous sore throat- diphtheritic sore throat-which is, as a general rule, a very formidable malady. You see then, gentlemen, that under such circumstances, as I have now been supposing, it was important to be acquainted with the specific character of the two diseases so similar in appearance ; for you might in the one case mistake a malady naturally benignant for one of formidable char- acter, and in the other you might prognosticate a mild attack, while the case was destined to terminate in death, or in a long and checkered Conva- lescence, retarded perhaps by paralysis more or less general, and more or less persistent. 454 SPECIFIC ELEMENT IN DISEASE. I need noton this occasion multiply examples to illustrate this point; for we shall only have too many opportunities of returning to the subject of the specific element of disease, which, as I have said, constantly presents itself in the course of the clinic. I now come to that aspect of the subject which bears on therapeutics. Gentlemen, to cure, and, when that cannot be done, to alleviate the suf- ferings of patients, is the object of medicine. The fact that the term medi- cine is derived from the Latin verb mederi, signifying to take care of, to apply a remedy, to cure, sufficiently points out the nature of our mission. Thera- peutics, as it comprises the study of the means by which we hope to carry this out, is consequently the most important department of our art, and, as you know', it is by far the most difficult. While treatment is dependent upon the experience, talent, and tact of the physician, it is still more sub- ordinate to the nature of the disease which he wishes to cure, to particular conditions under which the disease exists, to the peculiarities in the organi- zation of the patient, and to a host of circumstances too frequently unknown. The treatment of diseases necessarily rests upon a knowledge of their symp- toms, but it is also based in a special manner upon a knowledge of their causes and their natural history; and it is from the latter description of knowledge that a just appreciation is obtained of the important part per- formed in disease by the specific element. How is it possible to estimate the value of a method of treatment, or form an opinion as to the efficiency of a remedy, if the operations of nature -to use an expression of our predecessors-are ignored, operations which are different in the different species of diseases ? By not discriminating between these different species, do we not incur the risk of attributing great virtues to medicines which have in reality no remedial power, and of refusing to admit that others possess any therapeutic properties, al- though their utility, when administered under suitable circumstances, is undoubted. It is thus that we explain the fact that some have extolled pretended substitutes for cinchona, while others have blamed cinchona for transform- ing intermittent fever into malignant dothinenteria. The former had to do with simple cases of common continued fever, which would have got well of themselves, and which were at the commencement invested with the intermittent form ; the latter had to do, not with marsh fevers, but with cases of dothinenteria which had an intermittent type at the onset- such were the cases of fever the fatal progress of which was not arrested by cinchona. This is a topic to which I have already directed your atten- tion when lecturing on dothinenteria. In the same way, if a simple colitis accompanied by bloody stools is mis- taken for dysentery-a mistake which I see committed every day-it is impossible to avoid very erroneous conclusions in therapeutics. It is sup- posed, for example, that dysentery has been cured by a few leeches and emollient enemata, because in the cases in question there existed profuse bloody discharge, frequent stools, much straining, and high fever; whereas, in reality, the affection was one from which there would have been recovery in a few days, without any treatment whatever having been employed. Confronted with a case of real dysentery, the practitioner applies the same treatment he followed, as he thought with such amazing success, in the case of colitis, which would have got well had he refrained from all treatment, and he is astonished at its failure. You are called in to a patient suffering from great dyspnoea. His respi- ration is accompanied by a whistling in the larynx, which at once attracts your attention : on carrying your finger behind the base of the tongue, you SPECIFIC ELEMENT IN DISEASE. 455 discover that there is swelling of the epiglottis and aryteno-epiglottidean ligaments; on making pressure over the larynx, pain is caused. You are told that the person began to lose his voice two or three months ago, and that from that period, it had become feebler and feebler, till at last there was complete aphonia. Inspiration, at first whistling only during sleep, or after walking rather quickly or ascending a stair, has become similarly characterized when the patient is in repose : the oppression of the breath- ing has increased so rapidly, that when you are summoned, you see that unless a change for the better very soon take place, tracheotomy will be the sole remaining means of preventing death. Upon inquiry, you learn that the cedema of the glottis, depending upon serious lesions of the larynx, the cartilages of which are perhaps necrosed, or at least the mucous mem- brane of which is ulcerated-you learn that the laryngeal affection was some considerable time preceded by other local symptoms. The individual is stated to have had chronic coryza, characterized by a bad nasal dis- charge, to have thrown off crusts from the mucous membrane of the nose, from which organ a fetid odor is exhaled : you find that he has also had tumors on the bones. Without proceeding any further, you diagnose syphilis, and forthwith institute a system of treatment under which re- covery proceeds. From the suffocative seizures having been of so formi- dable a kind as to place the life of the patient in imminent peril, you have performed tracheotomy ; and in doing so, you have been gware that your operation, by retarding death, justified the hope of the patient being re- stored to perfect health. By a fortuitous concurrence of circumstances, such as often happens hi practice, you may at the same time have been sent for to attend another patient also affected with oedema of the glottis, but in whom you have found the disease associated with the tubercular diathesis. Now, if in the latter case, taking into account only the condition of the larynx, if, ignor- ing the specific cause of the disease, you try to obtain, by the same means, results similar to those obtained in the other case, you will inevitably fail. You may see in the same ward of an hospital, three patients with neu- ralgia of the fifth pair: in one, the paroxysms return every day, and are characterized by horrible pains which continue for six or ten hours, accom- panied by lachrymation, coryza, and salivation: in another, the neuralgia returns four or five times in the twenty-four hours, is accompanied by the same phenomena as in the first case, but only lasts for two hours: in the third patient, the fits recur at least every two or three hours, and last at the most for a minute, but they occasion agonizing pain, and are accompanied by convulsive movements of the face. The three affections are apparently similar, and occupy the same seat: the first, being an intermittent fever in a metamorphosed form will yield to cinchona: the second will be advan- tageously attacked by preparations of iron, if connected with a chlorotic condition of the patient, or by veratria, colchicum, or the external use of belladonna, if the case is rheumatic neuralgia consequent upon a chill: but the third will resist every kind of treatment, for it is tic douloureux or epi- leptiform neuralgia. A great many similar facts might be adduced, but from those now stated you can understand that in treating diseases it is absolutely necessary to bear in mind their specific element. I must state, however, that in some cases a knowledge of this element proves of very little consequence. In eruptive fevers, for example, following their regular course, the interven- tion of art is either quite useless, or very rarely of any benefit. I have hitherto spoken only of the specific character of diseases; and now I have a few words to say regarding the specific properties of medicines. We 456 SPECIFIC ELEMENT IN DISEASE. need not be long detained by this subject, if we adopt Parr's definition of specific remedies, and understand by that term only those medicines, which, like quinine in intermittent fever and mercury in syphilis, produce always, and in all patients, the salutary effects attributed to them-acting upon the malady in virtue of an unknown power, attacking in a direct manner its very essence, without its being necessary for the prescriber to take into ac- count the form in which the symptoms appear. We should very soon ex- haust the list of specifics, were we to restrict in this manner the application of the term; for there is not a specific remedy for every disease which has a specific character. Again, in practice, we do not always find specific remedies so efficacious as we have expected them to prove. Indeed, it some- times happens that medicines very justly called specifics not only fail, but eveu aggravate a malady, which, judging from their usual action, they ought to have cured. In such cases, we must abandon them, and have recourse to the use of remedies called rational, or in other words, to those which are indicated by the symptoms. Two women, who, at an interval of some months, successively occupied the same bed in St. Bernard's Ward, furnished facts in support of this proposition. They both had syphilis : mercury administered according to rule, and in a very guarded manner, had checked the progress of the symp- toms, when it became necessary to suspend the use of the medicine: the patients had fallen into a very bad state of chlorotic cachexia, rendering obligatory recourse to preparations of iron, under the influence of which their health was rapidly re-established. In other patients you will see still more formidable symptoms arise: you will see an extension of ulcerations which the mercurial treatment ought to have cicatrized; at other times the alimentary canal becomes irritable, fever is set up, and a pseudo-syphilis supervenes, complicating and altering, without curing, the true syphilis. In short, gentlemen, the action of specific remedies does not materially differ from the action of those called rational. The curative action of both is preceded by a vital action, which they excite: this may be called their immediate or physiological effect. The difference between their operation consists in the specifics exerting a special and direct influence upon the pathological actions which they modify, their immediate effects merging into the remote or curative effects; while in respect of the remedies called rational, the two kinds of effects appear distinct from one another. Without stopping longer to consider this scholastic distinction, suffice it to say, that medicines which modify the organism in a pathological state, in the same way that hygienic agents modify the organism in a state of health, have properties common to the whole class of medicines to which they belong; and only excite in the economy a common or general action, such as stimulating or depressing, irritating or calming. But along with these common properties, they each possess special properties which pro- duce specific effects; and the two kinds of properties, inasmuch as they exist in very variable proportions,' also manifest themselves in very differ- ent ways, according to. the individual predispositions of the subjects to whom the medicines are administered. This is what I understand by the specific action of medicines. To develop fully this subject, which embraces the whole domain of thera- peutics, would carry me far beyond the limits which I have prescribed for myself, as it would oblige me to review, if not all medicinal substances, at least all systems of medicinal treatment. I refer you, therefore, to the treatise on therapeutics which I have published in conjunction with my colleague and learned friend Dr. Pidoux; and in particular I ask you to read that CONTAGION. 457 portion of it in which we speak of substitutive treatment [medication sub- stitutive], a method of proceeding entirely based on the existence of a specific element in disease, the doctrine which we have now been briefly considering. LECTURE XXIII. CONTAGION. Definition.-Parasitical Diseases are not included.-Spontaneous Development of Morbific Germs.-Infection.-Infectious Diseases may become Conta- gious.-Dormant State of Germs.-Difference between Infection and Con- tagion.-Morbific Matter.- Conditions of Contagion: inherent in Indi- viduals and in Germs.-Immunity, Temporary and Absolute.- Conditions as to Age and Previous Contamination.-Acclimation and Habit.-Ap- parent Immunity.-Modes of Transmission.- Contact.-Direct Inocula- tion.-Inhalation. Gentlemen : The question of contagion is so intimately connected with that of the specific element in disease, as to form its necessary complement. The term contagion has been very variously defined; but the definition which seems to me to be the most accurate is that of Dr. Anglada, of Mon- pellier. It may be objected to on account of its length, but if this be a fault, it is one which must be attributed to the nature of the subject, and not to the author: in fact, it is on account of its completeness that I prefer it to other definitions. Contagion, adopting the definition of Dr. Anglada, I regard as "the transmission of a disease from one person affected with that disease to one or more other persons through the medium of a material cause [principe materiel'], the product of a specific morbid elaboration : this material cause communicated to an individual in a state of health determines the same phenomena and symptoms in him as were observed in the individual from whom the germ proceeded."* The necessity of the transmitted material cause being elaborated excludes from this definition parasitic diseases, which have been considered conta- gious by some physicians. In fact, itch, porrigo decalvans, thrush, &c., though communicated from person to person, cannot be looked on as contagious affections. Were we to admit that the acarus scabiei, tricho- phyton tonsurans, and oidium albicans are transmissible by contagion, it would likewise be necessary to hold that the parasitic animals which infest the exterior of the body, such as bugs, fleas, and the different kinds of lice, are also similarly communicated. But it has never occurred to any one to maintain such a proposition. I grant, however, that there is a certain analogy between parasitic and contagious diseases ; for while it is impossible for any one to say that lice are contagious, such a statement might be made with some verisimilitude in respect of the trichophyton of porrigo decalvans and the oidium albicans of thrush. Pushing matters to the extreme, it might then be alleged that the contagion of small-pox is simply a parasite, * Anglada: Traite de la Contagion, pour servir a 1'histoire des Maladies Con- tagieuses et des Epidemies. T. i, p. 12. Paris: 1853. 458 CONTAGION. which, like the oidium albicans is transmitted from one person to another. I anticipate the objection which will be taken to this line of argument, and I confess that I am in a rather awkward position to reply to it, as I hold that contagious diseases sow themselves by seed, and are consequently trans- mitted by germs. Still, I stand out for the distinction which I have drawn, maintaining that it is established by the capital fact that there is this difference between contagious and parasitic diseases, that in the former, the material morbid cause eludes my observation, while in the latter, I can lay hold of it. I can see, and I can isolate the mycelium of thrush, the tricho- phyton of porrigo decalvans, and the acarus of scabies; and, placing them in the field of my microscope, I can study and describe their characters. This I could not do with the morbific germs of small-pox, measles, or scarlatina, which, unlike the parasites, have not an independent existence, but require an organized and living substratum, to enable them to exist, and to show that they exist. Other affections, which by an overstrained employment of the term, have been called contagious, are also excluded from Anglada's definition. Every day I hear people say that laughing and yawning are contagious. The expression must be regarded as only a figure of speech: according to the same phraseology, certain nervous diseases are contagious. Who does not know the history of the women of Abdere, of the nuns of Loudun, of the choreomaniacs of the middle ages, of the convulsionaries of St. Medard, and a hundred other similar histories, which have been a hundred times told. In these cases we cannot, speaking the language of medical science, use the term contagion; we must employ the word imitation. Infection, when used to signify a morbific cause, is frequently employed to point to something different from or in contrast with contagion: it differs from, but does not exclude contagion. Frascator was the first author who thoroughly appreciated this distinction: his researches into the nature of syphilis led him to study the question. In his work "De Contagionibus," he wrote these words: " Qui hausto veneno pereunt, infecti esse diciinus, minime autem accepisse contagionem."-Of those who die after taking a poisoned draught, we say that they are infected: we do not say that they have received contagion. Frascator established the differences which he pointed out: I am also now going to establish them. A person is stung by a wasp, or bitten by a serpent: the venom introduced into the system forthwith produces symptoms which, according to the circum- stances, are more or less serious, or fatal: this is infection. If it be objected, that the germ of the disease coming from an animal and being by it transmitted to a man, contagion might be averred according to Dr. Anglada's definition, I reply by quoting the very terms of the definition itself, from which it appears, that while there has been transmission of a germ developed within a living organism, that transmission has not taken place from a sick to a healthy individual, nor has there been anything morbid in its elaboration within the animal which produced it. To use Frascator's expression, there has been a poisoned draught, and nothing more: the manner in which the haustus or the absorption has taken place is of no consequence. A person suffers from symptoms resulting from Unwholesome diet, from the daily use, for example, of flour containing a certain admix- ture of ergot of rye: in such a case, could it be said that there had been contagion? No: but it could be correctly stated, that there had been infection. Or again, in place of entering the system through the medium of the digestive organs, the infection may have effected its entrance by the respiratory passages, as takes place in diseases occasioned by various deleterious gases. Here again is the poisoned draught: be it venom, CONTAGION. 459 poison, or deleterions gas, you can take hold of the morbific cause; but there are other cases in which the qause is quite unknown. Take the case of a man living in the vicinity of a marsh, and let us suppose that the ground in the neighborhood of his dwelling has been recently turned up: the most acute sense of smell cannot detect any unpleasant odor, vegetation is everywhere luxuriant, the air seems in all respects salubrious: the man nevertheless is attacked by illness-by intermittent fever. He has been infected by a morbific germ contained in that air apparently so pure: the germ, though it only reveal itself by its effects on a living organism, does not the less certainly exist. In this case, we should not say that there had been contagion, but that there had been infection ; for here, as in the other illustrations which I have adduced, there was no transmission of a disease from a diseased to a healthy person: the morbid cause which engendered the malady was not the result of a morbific elaboration within another animal. The definition of Dr. Anglada is sufficiently comprehensive to meet all these differences. When the diseases which are designated "infectious " originate under the conditions which I have just been pointing out, under conditions of a manifestly vitiated atmosphere, as well as when the vitiation is not cogniz- able by our senses, we say that there has been infection. But our science is completely at fault, when, without any apparent change in the telluric or atmospheric conditions of a locality, there supervene what are called epidemics. Thus, at the end of March, 1832, when cholera came for the first time to commit its ravages among us, the weather was cold and dry, with beau- tiful sunshine : there was no apparent change in the geological constitution of the soil, nor in the meteorological constitution of Paris; and yet the dis- ease as soon as it was developed spread with frightful rapidity. If trans- mission by contagion had been given as the explanation of this rapid spread of the disease, it would most certainly have been at once confuted by the manner in which the epidemic dealt its first blows. It would have been necessary to seek the explanation in some general influence existing in the external world ; or, in other words, to admit infection, without being able to demonstrate the cause. There is another circumstance which it is necessary to take into account. If a malady believed to be contagious is only propagated in the same place, and does not extend beyond the locality, even when a large number of con- taminated persons are assembled together and are in contact with healthy persons, the contagiousness of the disease is disproved, and we say that it is only infectious. But I have often asked myself, whether sojourn in an infected place does not induce a predisposition in virtue of which the slightest contagion might act energetically, although the same contagion increased tenfold in power would be incapable of affecting an organism not predisposed by local infection ? I have always been astonished at the immunity sometimes enjoyed in a town where there prevailed an epidemic reputed not to be contagious, by persons who carefully avoided communi- cation with the sick. Here, gentlemen, arises the great question of spontaneous origin of epi- demic and contagious diseases simultaneously affecting large numbers of persons. Can diseases really arise spontaneously? Or, are they in some sort of way innate in the human species? Are they, as our predecessors said, originally present, their power remaining in posse, ready to manifest itself, waiting to enter in actu, upon favoring circumstances arising? Some phy- sicians adopt this latter proposition : in their opinion, the germs of disease 460 CONTAGION. are coeval with the human race, every individual having them in his body, apothecam hoc virus recondentem quivi# homo in se gerit, and they suppose that sooner or later these germs develop fermentem morbosum, nunc citius nunc serins actuosum redditur. This opinion, in former times maintained by men of the greatest eminence, though opposed by others of equal repute, has still some supporters. It does not, however, require a prolonged study of the question to side with those who deny the pre-existence of morbid germs, and believe in their spontaneous development. To arrive at this conclusion, it is only necessary to remember that some of the most con- tagious diseases, such as pox and small-pox, were unknown to Hippocrates, Celsus, Aretseus, and Galen, and consequently, were non-existent in the times of these great observers. As I formerly remarked, when discussing this subject in relation to vaccination, they could not possibly have failed to describe diseases possessing such precise characters, had they seen them. Pox, as you are aware, was not very well known till after the fifteenth century, although historians mention its existence in the times of the Cru- sades. There is no positive mention of small-pox till the seventh century, as is stated by Sprengel in noticing an epidemic of that disease which occurred in 565, and another which occurred in Arabia in 572.* Is it possible to believe that the germs of the disease were coexistent with the human race, and remained for so many ages in a state of incubation ? Spontaneous development, then, in respect even of the most contagious diseases, must be admitted. As contagion necessarily implies the presence of two individuals, the one the giver and the other the receiver of the morbid germ, it is a truth, so self-evident as not to require to be stated, that in the first sufferer from the disease its origin must have been spontaneous, though wholly under the influence of unknown causes. While there is reason to believe that at present some diseases, such as syphilis, small-pox, and measles, are always reproduced by contagion, that that is now their sole mode of originating, there are other maladies which we constantly see arise spontaneously. Does not rabies become developed in animals of the canine and feline species under the influence of particular causes, irrespective of any contagion or antecedent inoculation? The cases are numerous and indisputable. It is so likewise with the malignant car- buncle [sang de rate] in animals of the ovine species: this disease is spon- taneously developed by sheep under the influence of certain telluric, atmos- pheric, and alimentary conditions. Interesting observations made by physicians of the department of Eure-et-Loir, an account of some of which you will find reproduced in the painstaking work on Anthrax Carbo, by Dr. Raimbert of Chateaudun, establish this fact in a most conclusive man- ner and also show that special conditions of soil and air were inherent in the localities where the sang de rate was decimating the folds, while the disease did not show itself in other districts unless imported into them by infected sheep. But whatever may have been the causes which originated these diseases, they have the power of reproducing themselves by contagion. The mor- bific germ, which in its first generation was of necessity spontaneous, repro- duces itself within the body, and, in its turn, furnishes other identically similar germs capable of continuing the morbid species, always producing in the individuals who receive them effects the same as'those which were * Sprengel: Histoire de la Medecine depuis son origine jusqu'au 19esiecle; traduite de 1'allemand par Jourdan, t ii, pp. 198, 199. Paris, 1815. i Raimbert : Nouveau Diet, de Medecine et de Chirurgie Pratiques. Article " Charbon." T. vii, Paris, 1867. CONTAGION. 461 manifested in the individuals whence the germs came; and being capable in the same manner, without any., change of character, of perpetuating themselves in indefinite succession. For the accomplishment, however, of this transmission, it is necessary that it should take place between individuals of the same species. When there is diversity of species, the germ either ceases to be transmissible, or, when it does pass from the one species to the other, it produces different effects. In relation to the first point: rabies, for example, is communicable from the dog or cat to man, and from the dog to other animals, producing in all of them symptoms similar to those observed in the animal from which they were transmitted ; but there stops its capability of transmission : it is only communicable by man and individuals of the genera canis or fells. In 1826, during my internal at Charenton, I several times received on the face, lips, and eyes, the saliva of patients affected with rabies, without any resulting inconvenience. Recently, also, my chef de clinique, Dr. Dumont- pallier, having punctured himself with an instrument which he had used in making the autopsy of a patient who had died of rabies, did not expe- rience any consequences from this accident, though he dreaded their occur- rence. M. Raynal of Alfort inoculated several dogs with the saliva of the same patient, collected both before and after death ; but in none of the cases was there any result. In relation to the second point-let me recall to your recollection the remarks I made, when lecturing to you on vaccina, regarding the transfor- mation of the disease in horses called grease [eaux-anx-jambes] into cow-pox, and of cow-pox into vaccina; and let me also recall to your recollection the mutation of ovine malignant carbuncle into anthrax carbo and malig- nant pustule. It would appear that in these cases, by being cast into a particular soil, the morbific seed is changed, and the resulting species mod- ified : so obviously is the change dependent on the nature of the soil or substratum, that malignant anthrax inoculated from cow to sheep-inoc- ulated under certain conditions-appears in the latter as ovine malignant carbuncle [sang de rate]. Let us now resume the subject of infection. In whatever manner infec- tion takes place, whether it be by a miasm or a virus, or by the agency of an unknown cause, contagion is not excluded. I have just proved to you that rabies and ovine malignant carbuncle undoubtedly become contagious, and I could establish the same proposition in respect of other diseases which like them are from the first infectious. Dysentery and the typhus of camps are striking and unchallengeable ex- amples of this. Our latest and glorious campaign-the Crimean campaign -unfortunately furnished us with a new opportunity of judging the merits of this question. The typhus which so cruelly struck down our soldiers was, as is usual, developed under the influence of overcrowding, or, to speak more correctly, under the influence of the assemblage of a large number of men in one place. The morbid germ, produced spontaneously amid con- ditions belonging to the external world, and elaborated within living organ- isms, passed by contagion to, and produced typhus in, other persons who had not been subjected to the same conditions as those originally attacked: through the sole influence of contagion, the typhus seized the victims, not only in the country where it arose, but likewise in countries distant eight hundred leagues: it was brought among us by invalided soldiers, and at- tacked persons who had never left Paris. As you know, gentlemen, the nursing sisters and servants at the military hospital of Val-de-Grace fell under this scourge when ministering to soldiers of our army of the East who 462 CONTAGION. were under treatment for typhus in that institution. You will find the facts to which I refer stated in a work on the subject by Dr. Godelier, Professor of Clinical Medicine at the Val-de-Grace.* Thus you see that typhus, which was originally caused by infection, ultimately becomes quite as contagious as small-pox. The same statement is true in respect of dysentery and other epidemic diseases. It is necessary, however, to guard against a misunderstanding of this question. Sometimes, diseases are regarded as infectious which are exclu- sively contagious. This mistake arises from not investigating into their starting-point, or from not being able to discover it. In this way, the view that they are not contagious, and have been spontaneously developed, is adopted. No doubt, as I have remarked, these diseases were at some par- ticular period produced under influences totally unconnected with conta- gion ; but that period is very remote from the present time, and since that time, whenever it may have been, they have always, as now, been repro- duced by contagion. I admit that it is often exceedingly*difficult to discover the source of the malady. A person takes small-pox: in spite of all the care with which you set yourself to find out where he contracted it, you fail to do so; the patient tells you positively that he has seen no one who had the disease, that in the house where he lives, among his acquaintance and among all with whom he comes in contact, he knows of no case of small-pox. You then say the disease has been spontaneously developed. But this indi- vidual has perhaps touched the garments of a man who died of small-pox; perhaps he had gone into a room where there had been, at a more or less distant date, persons suffering from small-pox. The contagion of the malady, difficult to demonstrate in the great centres of population, can be more easily followed up in small places ; on a former occasion, I was at some pains to establish this point. Even in Paris, however, we sometimes have an opportunity of tracing back the contagion to its source. In 1827, I attended, in the Rue de 1'Echiquier, in Paris, a young woman with small-pox. She lived with her mother, a poor linen-draper. Both women inhabited the ground-floor, which consisted of one room divided by a high screen. The division next the street was the shop, in the compartment behind the screen was the one bed in which mother and daughter slept. During the entire duration of the case of small-pox, the neighbors came as of wont to make their pur- chases, and none of them had any suspicion of the danger which they thus incurred. At that time I lived in the Rue de 1'Echiquier, and so was enabled to watch carefully the development of a perfectly local little epidemic. In less than six weeks, seventeen of the patient's neighbors were attacked with small-pox : and I ascertained from the mother, that the persons first seized in each family were persons who had come to make purchases at her shop. Now, as no one knew how the disease had spread, the different medical men who were called in remained convinced that it had been spontaneously developed. It is necessary to enter still further into details, so as to enable me satis- factorily to explain my opinions. In 1854, the Wellington, an English ship, sailed for the East, having on board a regiment of infantry. Some days after leaving port, small-pox broke out, and in a short time a great many soldiers were infected. This ship put back to Plymouth, where she was thoroughly cleaned in every part, * Godelier: Memoire sur le Typhus observe au Val-de-Grace de janvier a. mai, 1856. [Bulletin de VAcademic de Medecine, t. xxi, p. 887.] CONTAGION. 463 and in fact made as good as new. Some time afterwards, when supposed to be quite purified, she sailed for the Crimea with troops. After being fifteen days at sea, small-pox reappeared on board, and made new victims: cases also occurred among the wounded whom the Wellington borught back to England from the Black Sea. A second time, this ship was sub- jected to purifying processes : it was supposed that every possible precau- tion had been taken, and it was hoped that she had been rendered a salu- brious habitation : nevertheless, on her third voyage, the disease declared itself a third time. It matters little how the first epidemic was developed : but let us examine into the source of the disease in the second and third voyages. When the first soldier took small-pox, more than nine days, that is to say, more than the ordinary period of that disease's incubation had elapsed since the ship had left England, so that one might come to the conclusion that the pestilence had been spontaneously developed. But, would it not be more reasonable to infer that the Wellington had retained contagious germs since her previous voyage ? Has not Dr. Melier, in his learned report on the yellow fever which raged at St. Nazaire in 1861, proved that the ship Sainte-Marie, from Havana, was the source of the contagion of the yellow fever which broke out among the men employed in unlading her at St. Nazaire ?* He has shown you the disease, transported to a great distance from its original home to a new locality, and there passing by contagion from man to man. My honorable colleague, Dr. Chailion, fell a victim to it, having con- tracted the contagion from remaining some hours in attendance upon one of the workmen engaged in discharging the cargo of the Sainte-Marie. During last century, there was ordered the judicial exhumation of a per- son who had died of small-pox a great many years previously. The grave- digger who performed the exhumation, and some persons who were present when it was being done, took the disease: it soon afterwards broke out in the little parish in which occurred the events now mentioned, and where for many years small-pox had not been seen. This history has an apocry- phal appearance ; but, nevertheless, it is related by authors fully deserving of credit. It teaches us that the variolous germ, wrapt in a shroud so to speak, but in reality only deposited on the planks of a coffin, was capable of affecting a considerable number of persons, and of developing itself with formidable energy whenever it met with conditions favorable to develop- ment. The preservation of the morbid cause on board the Wellington is a not less credible fact. Morbific germs may remain inactive for a certain time, adherent to inor- ganic bodies, as is illustrated by the practice of former days of inoculating by means of a thread impregnated with variolous matter. In this way, they may remain hidden for days, months, or years, waiting to manifest their presence, till they meet with conditions favorable to their evolution. Have not the experiments of Spallanzani and of Reaumur disclosed facts quite as extraordinary, relative to the development of animal and vegetable germs? Did not the first named of these illustrious inquirers into the secrets of nature observe the development of infusoria in dust col- lected from the gutters of roofs exposed to the rays of an intensely ardent sun? One drop of water sufficed to bring about the resurrection. And have we not recently been present at spectacles equally marvellous ? Are not you all acquainted with the history of the seeds found in the tombs of the Pharaohs, which germinated and fructified after a lapse of more than * Melier : Relation de la Fievre Jaune survenue a Saint-Nazaire en 1861. [M&moires de V Acadimie Im[driale de Medecine, t. xxvi. Paris, 1863.] 464 CONTAGION. three thousand years, just as if they had been gathered on the previous day from their parent plants ? Those among you who take an interest in botanical studies have observed a well-known appearance presented by the flora of the woods. By the cutting down of the wood, this Hora is so greatly modified, that after the interval of a year it is impossible to recognize it. In the situation where you pre- viously found plants of a particular species, others of a totally different kind have appeared, which have not been seen since the first time the wood was cut down twenty-five years previously. During twenty-five years, the germs have remained buried in the ground, waiting for the air and sun requisite for their developing themselves. It may be said that the seeds have been sown by the wind, or that they have been brought from afar by birds, just as we see crows and magpies carrying kernels and nuts which they have gathered, and accidentally dropping them here and there. But how are we to explain the number and variety of the plants which appear under the circumstances which I have described ? In particular, how are we to explain the fact that according as the wood is thick or cut down, we always have the one and not the other kind of plants? Let me now return to the consideration of morbid germs. I have referred to what occurred long ago at Gibraltar. In 1802, the English troops, on their return from Egypt, brought ophthalmia with them to Spain, a disease which had till then been unknown on the coasts of the Peninsula. From that time, ophthalmia attacked in succession the different regiments which constituted the garrison of Gibraltar. Such at least was the state of matters in 1828, when 1 was sent there on a mission: the English surgeons showed me soldiers affected with Egyptian ophthalmia, although during the preceding twenty-six years the bedding and furniture of the barracks had been frequently renewed: everything had been done that could be thought of to improve the sanitary condition of the barracks. Here is another case in point. The history of contagion abounds in such cases. In 1845, a woman was admitted to my wards at the Necker Hos- pital with all the symptoms of glanders, of which she died. Where did she contract this disease ? She worked at the establishment of a merchant of horsehair, where her occupation was to twist hair which came from Buenos Ayres. Mark well this circumstance: it is a fact of chief im- portance that all the hair in that establishment came from Buenos Ayres. Well, the woman contracted glanders, and the only way in which we could account for this was the nature of her occupation : she had never had the care of horses, nor had she ever had any communication with persons so employed. If there are any cases in which we can suppose that an infec- tious germ was spontaneously developed, this is certainly one of them ; and yet, extraordinary though it be, the cause of the contagion seemed to me quite evident-the contagium of glanders existed in the South American horsehair. Nor does this case stand alone: it is well known that glanders unfor- tunately too often attacks workers in horsehair, just as malignant pustule attacks workers in wool. To me, and other's, the facts now stated are irre- sistibly convincing, and prevent disbelief in the possibility of a prolonged conservation of contagious germs. In following out the details of the evolution of these germs, I must constantly rest upon analogies, a proceeding always necessary when direct facts are wanting. I propose to take my analogies from natural history and agriculture. Some seeds will grow anywhere. Place them under certain conditions in respect of heat and moisture, and they will spring up in all places CONTAGION. 465 and at all seasons. But there are other seeds which do not behave in this manner. Make, for example, in February, a seed-bed of cherry trees, casting a thousand cherry-stones into a thoroughly prepared soil. During April, you will see some stems coming up; if the twentieth part of your seed spring up, you ought to be satisfied. In the following April, more of your seed will germinate ; and again, in the April of the succeeding year, an additional quantity of your seed will arise. If, in these successive evolu- tions at intervals of twelve months, occurring always at the same time of year, you look to the influence of the seasons for an explanation, I ask- by appealing to what influence can you explain, why seeds placed under precisely the same conditions of soil, air, sun, and water have not ger- minated simultaneously ? The germs of some animals offer similar examples. Reaumur, wishing to study the habits of the bombyx pavonia major kept several chrysalides of this kind of butterfly in the sand-box of his writing-table. Some of them hatched, and others seemed as if they were dead, till he touched them with the point of his penknife, when he found that he excited slight movements. He kept them: and next year at the same period, almost to the very day, he saw an additional number of butterflies come forth : also tw'elve months later, and again almost to the day, a third hatching took place. Is there not something very curious in this repose of germs ? Is it not singular that chrysalides of the same butterfly, of the same age, and placed under precisely similar conditions, should have been hatched at intervals of exactly one and two years ? Why may not the seeds of disease comport themselves in this respect like the seeds of plants and the larvae of insects? Conditions of air, sun, water, and place can no more explain the successive evolutions of the germs of contagion than they can explain the successive hatchings of the larvae of Reaumur's bombyx. It would appear that the germs of many diseases like the germs of some animals and vegetables are only developed at determinate epochs. Yellow fever, for example, has never prevailed in Europe except from July to September, whatever may have been the meteorological constitution of the other months of the year. The disease has always appeared within that period, whether it has been a period of heat or cold, of drought or rain. It has in this respect a pecu- liarity similar to that of some birds which always moult at the same season of the year, in whatever climate they may be living. The parrots of the southern hemisphere change their plumage in March, the time when the temperature begins to be lower in their native regions: they, when brought to France, remembering their origin, if I may be allowed the expression, still moult in March, though in our latitude, at that season, the warm weather is only beginning, and though the birds of our country do not moult till September. But it may be said that no one has ever seen these morbid germs of which I have been speaking: no one has ever collected any of the poisons, the absorption of which gives rise to cholera, yellow fever, influenza, inter- mittent fever, and dothinenteria. That is quite true; and yet the persons who deny the existence of the germs really accept the essence of the propo- sition, and take exception only to a term, for they speak of miasmata and morbid causes, which they have not seen any more than they have seen germs. The recent labors of Professor Charles Robin, of which I shall speak immediately, seem to put us on the track to discover these germs of disease. The miasmata, or morbific causes, or germs-the term matters little- may remain latent, slumbering for a longer or shorter period, buried in inorganic substances: then, at a particular moment, under certain telluric vol. i.-30 466 CONTAGION. and atmospheric conditions, with the nature of which we are unacquainted, but the influence of which no one denies, they develop themselves in per- sons predisposed to receive them. I ask those who refuse to admit the pre-existence and slumber of germs, if they have found the intervening conditions which alone they put forward, and under the influence of which, yellow fever, after having been absent from a district for ten, twenty, or thirty years, all at once begins to rage with an intensity equal to that manifested at its first appearance ten, twenty, or thirty years before. During this long interval, have you detected any change in the atmospheric constitution of the locality? Have its meteoro- logical conditions appeared to be modified ? Do not deny that germs exist, because their existence is incapable of direct demonstration ; for you cannot prove in any more satisfactory manner the intermediate influences which you unhesitatingly admit. Have I not sufficiently established my proposition by citing the successive epidemics of small-pox on board the Wellington, and the installation of Egyptian ophthalmia in the barracks of Gibraltar? If we admit the existence of germs, to argue against their slumber, to explain their spontaneous appearance, by alleging that they have been borne by winds from one country to another, would be to substitute for one hypothesis, another hypothesis based on entirely false premises. Let me illustrate this point by referring to the yellow fever which pre- vailed at Gibraltar. The winds, it has been said, carried thither the germs of the disease: if so, why was there not one case in Spain, over which the north wind had passed, not one in Morocco, whence comes the south wind, not one in the islands of the Mediterranean Sea, nor in the countries which are nearest to it on the east and thp west? Still more, if we take into con- sideration the manner in which yellow fever stations itself, ravaging for ex- ample, a locality, and yet sparing places immediately adjoining, we are obliged to reject the hypothesis in which ignorance has tried to take shelter. Here, in a few words, is an account of the occurrences observed at Gibral- tar. You know the geographical position of the place. Gibraltar is seated upon a rock, which terrestrial convulsions of an antediluvian era have sep- arated by a strait from Africa, and is connected with Spain only by a slip of sandy soil, called the " neutral ground." The particular locality where yellow fever raged with greatest fury was that designated the "sea-gate," beyond which lies the neutral ground, where the pestilence stopped short. The population emigrated to that narrow sandy flat, and there established itself in tents, at a pistol-shot from the town. The emigrants, who never entered the town, had not one case of yellow fever among them; yet, they were so near the hot-bed of the disease, in such close proximity to the ditches of the fortress, that they could, so to speak, converse with the sick shut up within its walls. Does not this fact absolutely demonstrate, that the winds have no influence whatever in propagating, nor, a fortiori, in causing the outbreak of an epidemic ? The remarks which I have been making apply equally to infectious and contagious germs. The difference between the two I consider to be this: The infectious germs, engendered under unknown influences, produce cer- tain effects in the individuals who receive them: but there the effects stop- the germs die within the organisms which they infected. Originally engen- dered also under influences which equally elude us, the contagious germs develop themselves, and fructify within the organism which has received them. The contagious germ is, so to speak, conceived as the infant is con- ceived in its mother's womb: but more than this occurs-the germ assimi- lates the entire substance of the economy-totus homo morbus fit-the man CONTAGION. 467 who has received the contagion becomes a new centre of morbific emana- tions. Gentlemen, Van Swieten, in his Commentaries on the Aphorisms of Boerhaave, a book filled with many good things, gives his opinion on the matter now before us. In several places, particularly in treating of small- pox and gout, he speaks of the materia morbosa. In his chapter on gout, you will find the following passage: " Certe, videmus toties in morbis aliquid, non nisi effectis suis in corpore humano cognitum, turbare totum corpus, et assimilare in suam naturam humores antea sanos : qui humores sic mutati constituunt materiam mor- bosam dictam medicis, et quse materies morbosa potentiam ssepe habet propagandi eundem morbum. In dysentericis putridum miasma recipitur ab adstantibus et quamvis illud infinite parvum fuerit, omnes humores hominis sani in tubum dysentericum con vertit. Parvo vulnusculo cutaneo tantum, applicatur filum pure varioloso imbutum: susceptum illud con- tagium silet per plures dies, dein febrem accendit, totum corpus turbat, et convertit humores sanos in suam indolem ita ut quandoque numerosee pus- tula?, omnes pure contagioso plena;, per omuem corporis superficiem nas- cantur." This something, which reveals itself only in the effects which it produces, this putrid miasm, this morbific matter, is not perhaps any better known to us than it was to the medical observers of old times ; although recently one of our most distinguished men of science believes that he has demon- strated its existence. According to Professor Ch. Robin, morbid germs are formed by bodies holding a first place both in respect of their material importance and their properties. These bodies are the. coagulable com- pounds called organic substances, natural animal and vegetable substances, formed both accidentally and artificially. I am sure, gentlemen, that you will be pleased by my quoting some of the views on this subject which have been enunciated by Professor Ch. Robin. lie says : "Whether solid or liquid, or whether suspended in the vapor of water, these organic substances present this peculiarity, that when they become altered, they transmit by simple contact to healthy organic substances, the kind of alteration which they have undergone, or a similar kind of altera- tion. For the accomplishment of this, it is not necessary that the quantity of the altered organic substance offer a determinate relation in bulk to the substances modified by them ; as is requisite in the chemical actions exerted on one another by crystallizable compounds. Organic substances, the alteration of which has begun under certain conditions of temperature, moisture, &c., transmit this state by mere contact, or in consequence of molecular admixture with healthy substances, even when in extremely minute quantity, because the modification proceeds gradually from mole- cule to molecule. " It is by altered vegetable and organic substances that there are pro- duced certain epidemic diseases, such as typhus, dysentery, paludal, and other affections termed general diseases. Through the operation of the same cause, and by means of altered organic substances received into the stomach along with beverages and foocl, arise the majority of maladies similar to those I have just named, in which the entire economy is impli- cated ; or, to speak with more exactness, in which every organ presents disorders of nutrition, and consequently of every function performed by the organs. " As examples may be cited the typhoid, variolous, and scarlatinous 468 CONTAGION. fevers. In the same category may likewise be included the diseases which result from putrid and purulent infection. " Among these diseases are some which are pre-eminently contagious : others which have not been proved to be contagious : and also a different class of which it may be said that they are not in any degree contagious, so far as existing experience can be accepted as decisive on the point." " There exist," says Professor Ch. Robin, " peculiar conditions in virtue of which one individual exposed to the action of these organic substances is attacked, while another escapes: while one exhibits the symptoms in the place of his attack, another shows no symptoms till immediately after he has left the locality, or not till after the lapse of some days."* We shall return to this subject. In conjunction with this ably propounded hypothesis, I must mention M. Pasteur's new theory of fermentation. This eminent man of science has come to the conclusion, from experiments performed with extreme care, that fermentation is dependent upon sporules diffused in the air; and that each kind of sporule, recognizable by certain characters, possesses the property of originating in a particular medium a different species of fer- mentation. According to him, there are different sporules for the different fermentations-the alcoholic, lactic, &c. May there not also exist morbific sporules? May we not in this way explain the morbid fermentation spoken of by the older authors ? Bearing in mind the researches of Eidvelt of Prague, and those of Reveil and Chai vet into the composition of the at- mosphere in the Parisian hospitals, St. Louis and Necker, I concur with Professor Pasteur in believing that it would be very interesting to institute an extensive examination of this subject, to compare the organized corpus- cles disseminated in the atmosphere of the same place at different times, and of different places at the same time. It appears to me that such in- quiries would throw light upon the phenomena of contagion, particularly during periods when epidemics are prevailing. A sporule diffused in the atmosphere can live only in a latent form, like the grains of wheat in the Egyptian tombs. But if, like the latter, you place the sporule in a place suitable for its living, it will then develop itself, multiply at the expense of the elements with which it meets in the favorable medium, and, according to its species, originate the phenomena of the differ- ent fermentations. May it not be the same with the sporules of disease, which, floating free in the atmosphere, may be only waiting for certain favoring circumstances to enable them to reveal their existence, develop themselves, multiply, and produce the supposed morbific fermentation ? Has it not been said that pus generates pus ? Perhaps there is a pus-sporule to explain purulent infection ; and perhaps there is also a dysenteric sporule, and a choleraic sporule. If these sporules could be detected in the atmos- phere, the facts relating to contagion would be materially explained. To make that discovery it will be necessary to follow in the track indicated by Professor Pasteur, proceeding by experiments conducted with the same ability and patience which he has shown. I have pointed out to you the part played by the organic substratum, and by the specific nature of the ferments in the act of fermentation. I ought to state that Dr. Jules Lemaire, an eminent physician, has very re- cently demonstrated the essential importance of the nature of the medium * Bobin (Charles) : " Dictionnaire de Medecine dixieme edit., 1855: Article, Maladies ou Affections Generales; et 12e,1866: Article, Substances Organiques. See also, " Gazette des Hopitaux," 2d August, 1856, p. 361. CONTAGION. 469 in the intimate mechanism of fermentation.* In opposition to M. Pasteur, who considers that there is a special ferment for each kind of fermentation, M. Jules Lemaire makes out that there are neither special microphytes nor microzoa in particular fermentations, and that the existence of one or other is contingent upon the medium. Thus, in a liquid which is neutral or slightly oxidated, and contains organic substances in infusion, microzoa (bacteria and vibriones) appear, and by their aid fermentation is accom- plished. But if the substances are acid, it is then microphytes which are developed, and it is then, by their assistance, that fermentation takes place. But that is not all: in acid substances fermentation begins with microphytes, and when the acids have to a great extent become transformed, microzoa appear, the smell at the same time becoming extremely fetid: the changes take place in an inverse order when an originally neutral medium becomes acid, that is to say, the appearance of microphytes precedes the appearance of microzoa. These experiments have only a remote analogy to the much more com- plex phenomena of the contagion of diseases: I have only brought them under your notice to enable you to appreciate the very great difficulty of the subject. In fermentation, where the whole process is seen, the specific character of the ferments, or of the living agents of fermentation, is recog- nized : the contagion of diseases, on the other hand, proclaims the unim- portance of these agents and the omnipotence of the medium. In the act of contagion we can scarcely perceive the material agent, and are obliged to prove its existence by induction, or from analogy. Can morbific germs, infectious or contagious, remain in a latent state external to all organic life ? Recollect the epidemics of small-pox on board the Wellington, and the cases of ophthalnda at Gibraltar: remember the woman who died of glanders from having worked among horsehair from Buenos Ayres. In the same way a contagious disease desolates a family at a particular period, and then disappears, to reappear, however, after a cer- tain time with equal severity, but independent of any new contagion from without, there being in fact nothing to which the reappearance can be at- tributed, excepting that the germ of the disease had remained concealed where the family was living, in the hangings of the furniture and of the apartment, just as the variolous germ remained in the structures of the Wellington, as the germ of ophthalmia remained in the barracks of Gibral- tar, as the virus of glanders remained in the horsehair from Buenos Ayres. A girl of nine years of age was carried off by malignant diphtheria. On the first manifestation of the symptoms, her two sisters were removed to a distance from the house, and did not take the disease. But eight months afterwards, on returning home, the elder of the two was seized with diph- theria, which invaded the larynx, and I was called in to perform tracheot- omy. This child died, as her sister had died, from diphtheritic poisoning. Again, on this occasion, as soon as the disease was recognized, the surviving sister, aged five years, was sent oft'to the residence of her grandmother, but she carried with her the germ of the malady. Sore throat very soon declared itself, and in seven days croup necessitated tracheotomy, which was in this case a complete success. Two circumstances in the history of these children require to be looked at separately, viz., the preservation of the germ, external to the organism, and the incubation of the malady. By the term incubation, we must under- stand the time which elapses from the entrance of the morbific cause * Lemaire (Jules): Nouvelles Recherches sur les Ferments et les Fermentations. [Lu a Academic des Sciences, en Septembre et Octobre, 1863.] 470 CONTAGION. into the economy till it manifests itself by producing the symptoms of the disease which it determines. It is probable that the last of the three chil- dren received the diphtheritic poison at the same time as her deceased sister, the evolution of the malady beipg slower in the one case than in the other. The period of incubation is, at least in some diseases, as you know, longer or shorter in different persons according to their individual peculiarities. But however long the period of incubation may be, its duration is not indefinite; and if sometimes it appear to be prolonged beyond the ordinary term, there has not really been incubation. The morbific germ had not entered the organism, but had remained on the surface of the external tissues, exactly as in the cases we have now been considering, in which it was preserved in the clothes of a patient, the drapery of an apartment, or the woodwork of a ship. This explanation will be accepted when it is seen, that in epidemics, of small-pox for example, persons living in the very centre of contagion are not all simultaneously seized ; but that some are attacked immediately, and others much later, and too late to allow us to believe that the incubation began at the same date; while others again are not attacked for a longer or shorter interval after leaving the centre of contagion. In considering the question of contagion, it is necessary, not only to bear in mind the element of contagion itself, but also, and even more, the con- ditions necessary for its action. There are two factors: one is the morbific germ coming from without, and the other is the economy about to receive it. Here, as in every patho- logical and physiological act, there is required a stimulus, and also support for that stimulus, which Recamier called the reciprocative power; or, in other words, there is required a special aptitude in the organism to respond to the action of the stimulus. Permit me to return to these points, which I have already glanced at in my lectures on small-pox. Except by the relation between the stimulus and the support, how are we to explain the occurrences attributed to that which is called predisposi- tion? How are we to explain, why an individual may expose himself a hundred times to an icy cold, to sudden changes of temperature, without experiencing the least detriment, whilst the same person will take a severe catarrh, an inflammation of the lungs, or a pleurisy, from having been touched in a hot day by a current of mild air coming in behind him at a half-open window. The explanation is this: in the first case, there was a capacity for resistance, and, as we say, a negation of receptivity; while in the other case, the economy was-excuse the expression-quite open to receive the disease. It is therefore said with truth, that one does not gener- ally take a pneumonia proportionate to the intensity of the cause, unless there exist a predisposition to the disease. During the prevalence of what are called the common " medical con- stitutions," all morbific influences act in the same way, in virtue of the common aptitudes which these "constitutions" have imparted to different individuals-then, causes small and great produce similar effects. During an epidemic of influenza, for example, a current of cool air, and a chill when in a state of copious perspiration, occasion catarrh, which assumes the specific character of the prevailing epidemic. When cholera is epi- demic, the slightest indigestion will become the starting-point of an attack of cholera. You see, therefore, that both contagious and non-contagious diseases are contracted only when there is a special predisposition of the economy to receive them. When there is no such predisposition, the morbific germ perishes. There occurs exactly what occurs in respect of the act of reproduction in the CONTAGION. 471 animal and vegetable kingdoms, where it is essential that there exist a special fitness in the germs, and a special disposition in the individual who ought to receive them-a condition the nature of which it is often impossible to discover. So it is, that on one side or the other, there is something wanting which isessential. When fecundation does not take place, although the individual seem to possess the conditions necessary for conception, one cannot in an absolute manner attribute this result to a defect in the germ, and can only say, that in the case there was a want of the necessary apti- tude. When, on the other hand, fecundation does not take place, although the germ possesses the necessary aptitude, it cannot be said that there is an incapacity of being fecundated, but only that at that particular time the individual was not in a state suited to the accomplishment of the act. Finally, should fecundation not take place, notwithstanding that there exist both an aptitude of the germ and of the individual, it ought to be said, that the failure is occasioned by special conditions impossible to deter- mine. It is essential that there exist the favorable conditions which belong to the germ, and also those which pertain to the individual who ought to receive the germ, besides favoring circumstances external to both. A study of generation in plants and animals shows that numerous cir- cumstances occur unfavorable to the accomplishment of reproduction. In certain species in which this is particularly the case, the Creator has given an exceedingly lavish supply of reproductive organs. In hermaphrodite plants, the stamina, whose office it is to furnish the fecundating principle, are much more numerous than the female organs: for a single pistil, an in- finite number of organs secrete pollen. In the plants in which the male and female flowers are distinct, the number of male flowers is enormously in excess of the female. In animals, in fish for example, it is not unusual for the female to deposit a quantity of ova so vast that if all were fecundated, or at least if all were hatched, the rivers would hardly be able to contain the produce. It is the same in respect of morbific germs. Thank God ! when they are sown broadcast among populations, they do not all grow up: if they did, the world would speedily become an immense desert. But because all mor- bific germs do not prove contagia, we are not entitled to deny that they possess a contagious principle. Here is what occurs when diseases essentially contagious are epidemic: although I have already narrated the following facts, I must again cite them. The tag-sore, or small-pox of sheep [clavelee] broke out in a flock of five hundred sheep: fifty were seized, and remained with the rest of the herd. The diseased sheep lay in the same fold with the unaffected, and both ate their forage from the same rack : the litter common to the affected and unaffected sheep was soiled by the slime and pus from the former. A month later, fifty other sheep had the disease, and in five or six months, the epizootic malady had ravaged the herd: only fifty sheep were not at- tacked. There can be no doubt that the virus possessed its special apti- tude, since it affected nine-tenths of the flock. Why, then, was not the remaining tenth attacked? Why were fifty sheep spared? No one can deny their individual aptitude. The existence of this aptitude may indeed have been thus shown: of the fifty sheep which escaped the contagion when lying in the same litter with the diseased, eating from the same rack with them, constantly coming into the closest contact, mingling fleeces, soiling their noses with the discharges of the contaminated, one or more, long after the outbreak has terminated, will take the disease, simply from passing along a road which had been traversed by a flock in which there was per- haps only a single case of tag-sore. 472 CONTAGION. Human pathology affords similar examples. We every day see hooping- cough, measles, and scarlatina establishing themselves in a family by at- tacking one or two of its members; at a later period, after an interval of perhaps some months, the disease reappears, seizing individuals who escaped on the occasion of the first outbreak, though during it they were living in the midst of the contagion. Such is the history of an epidemic of diph- theria of which I have already spoken to you, as well as of epidemics of small-pox. In these cases, I again repeat, the seizures occur at so great an interval after the first exposure of the individuals as to make it impossible for us to suppose that the disease was during all that period in a state of incubation. When persons in the first instance escape, but do not ultimately resist the influence of the morbific cause, it is because they had at first a power of re- sistance, an absence of receptivity; that is to say, they did not till a later period possess that predisposition which is necessary for the reception and conception of the morbific germ. Some females conceive in consequence of the least possible amount of connection with the male; while others, after having had many times unfruitful connection, conceive by the same male on some particular occasion, there being no apparent difference in the con- ditions under which the fruitful and the unfruitful intercourse occurred. What happens in respect of persons, happens also in respect of diseases. You may unsuccessfully on two or three different occasions inoculate a per- son with a virus, the vaccine virus for instance, and, on making a fourth trial, employing virus obtained under conditions exactly similar to those in which that was taken which you used in the three unsuccessful attempts, you may see the vaccina develop itself, in one whom you were inclined to believe was devoid of aptitude to receive it. The remarks now made respecting contagious, are equally applicable to infectious diseases; it matters little whether the morbific germ is developed under the influence of particular telluric conditions, such as marsh miasma, or whether it has been conceived by an animal, as is the case with glanders, malignant pustule, or small-pox: in both classes of cases there must be a suitable relation between the stimulus and the support with which it meets. Infection'and contagion, then, do not take place proportionately to the quantity of the morbific germ, as some physicians profess to believe. As Professor Charles Robin has told you, quality is paramount over quantity; but it is still more important to take into account the aptitude of the germ, and the aptitude of the receiving organism. Not only is quantity of small consequence, but the history of generation in animals would actually seem to show that the active power of germs is in a ratio inverse to quantity, or at least inverse to the degree of concentration of the principles which con- stitute them. Here, again, let me borrow my analogies from Spallanzani. Passionately devoted to the study of the wonders of nature, proceeding in the path of discovery unincumbered by preconceived ideas, happy, as he advanced, to find difficulties which stimulated his inquiring genius, the search for a par- ticular truth leading, as he himself said, to the discovery of other truths spontaneously presenting themselves, Spallanzani belonged to that illustri- ous generation of ingenious attentive observers which embraced Fontana, Redi, Reaumur, Swammerdam, and Senebier, and which is continued in our day by our great scientific physiologist, Claude Bernard. The perusal of the work of the Italian naturalist carries along the reader, and affords more charming recreation than the most attractive romance. Many of you •are acquainted with Spallanzani's works on the subject of generation, and CONTAGION. 473 his experiments on artificial fecundation, made not only on the inferior classes of animals, but also on the mammalia. Spallanzani found that he could'fecundate the spawn of the frog and the toad by spreading over it the semen of the male, either by evacuating it by pressing on the abdomen of the animal, or by taking it from the spermatic vesicles; but that the fecundation of the ova of aquatic salamanders could not be accomplished in that manner. He was well aware that in them natural fecundation does not take place after the laying of the ova as in frogs and toads, but within the body of the mother; consequently, he was obliged to have recourse to other means, for he could not, as he himself remarks, fecundate foetuses after their birth. He repeated his experiments many times, " varying the proceedings in a thousand ways in respect of the quantity of semen employed, and in respect of the manner in which it was applied to the ova, sometimes touching them slightly with it, sometimes gently bathing them in it, and at other times quite soaking them in it; but he was always equally unsuccessful." Discouraged by his unavailing efforts, he was about to discontinue them as hopeless, when it occurred to him that he had forgotten, an important circumstance. He recollected that in his experiments on frogs and toads, fecundation was accomplished by bringing the semen into contact with the ova immediately upon their being discharged from the cloaca. The male, coupled to the female, holds her in a close em- brace, so that their posterior parts are kept in contact. In the salamander copulation proceeds on another plan, the ova being fecundated whilst they are within the body of the female; whereas in the frog and toad the ova are external to the female during fecundation. This condition of distance Spallanzani had lost sight of. During copulation the male salamander so places himself that the lower part of his head touches the upper part of the head of the female, their bodies forming an angle, the apex of which is con- stituted by the union of the two heads; or else the male and female place themselves nose to nose, in such a way as to have their bodies in close prox- imity, forming, however, a very acute angle. The male then shakes himself about, and squirts a copious jet of seminal fluid from his anal orifice, which, mingling with the water, becomes greatly diluted, and in that state reaches, and enters, the anus of the female. Bearing in mind this peculiarity, Spal- lanzani resumed his experiments. Suspecting that the pure semen was not in a state fitted to produce fecundation, and that its dilution with water was an essential condition, he caused salamanders to discharge their ova by pressing them on the abdomen with his fingers: he then placed the eggs in water in which he had dissolved a small quantity of semen : of twenty-seven eggs so treated, seventeen became developed. The failures, therefore, had not in this case depended upon a deficiency in the quantity of the germ. Now, what is true of physiological germs, may be said likewise of contagious and infectious morbific germs. I do not mean to say, that we are entitled to conclude from the facts now stated, that the active power of germs is in an inverse ratio to their quantity : I only conclude that we must take more or less into account the condition of quantity: quality is the condition of principal importance. This statement, I now reiterate, although I insisted upon it when lecturing upon specific influence. Thus, gentlemen, it appears, that quantity of germ, but still more quality of germ, aptitude of the individual by whom the germ ought to be received and conceived, and the relative circumstances in which the individual is placed, are the conditions which influence contagion and in- fection. These conditions, as I have said, are far from being always met with : CONTAGION. 474 upon this point, experience has given a distinct verdict. Some persons possess an absolute power of resistance : there are individuals who pass unharmed through every kind of epidemic, be it influenza or cholera, scar- latina or measles, small-pox or dothinenteria, typhus or yellow fever: there are individuals whom it is impossible to affect with the vaccine virus-in- oculate them twenty times, and you will obtain no result: in them, if I may use the expression, the soil is barren-in it the seed cannot germinate. There are others again, in whom the power of resistance is only temporary. It is, in general, difficult to find out the conditions upon which this power of resistance depends: in some cases, however, they can be got at, though we can never become intimately acquainted with them. Every farmer will tell you that pregnant ewes are less liable than other sheep to contract contagious diseases, but that as soon as they have brought forth their young, they return to a state of liability similar to that of other sheep. The same remark is to a certain extent applicable to women. Ma- gendie explained this fact by saying that the sanguineous plethora, which is usually more or less decided in pregnant women, renders absorption more difficult; and that after parturition, it again becomes more easy, in conse- quence of the plethora being diminished by depletion of the vascular sys- tem, and by the comparative emptying of the abdomen caused by the de- crease in the volume of the uterus, so that after parturition women and female animals resume their aptitude to receive the germs of contagious diseases. That is the physiological explanation. It is not for me to dis- cuss it. It is easy to understand why it should be accepted : but it mat- ters little whether it be received or rejected, as the fact will still remain. It has been alleged that great overflowings of the heart, such as arise from emanations of joy and maternal love, fortify the system against con- tagion, while depressing moral emotions, such as fear, increase its suscep- tibility. It is known that the ability to resist contagion varies with the age of the individual; there is less power of resistance in the youth than in the old man ; and, all other conditions except age being equal, old men resist contagion better than adults. Again, it is well known that an anterior contamination generally confers an absolute immunity from any subsequent contamination. In respect of small-pox, this is the case with very few exceptions. Though instances do occur of persons contracting indurated chancres several years after a first attack : though, consequently, there are examples of second attacks of syphilis similar to those published by Dr. Follin and other conscientious observers of unquestionable credit, such examples are rare, and do not con- trovert in the least degree the law of immunity as enunciated by Dr. Ricord. In fact, the statement applies to syphilis in the same manner that it applies to small-pox, measles, scarlatina, dothinenteria, and yellow fever; that is to say, that while the immunity acquired by a first attack is universally admitted to be the rule, it is also equally admitted that the rule presents a considerable number of exceptions. I have laid before you accounts of second attacks of small-pox, and you have yourselves seen such cases in the hospitals. You have also seen a well-marked similar occurrence in respect of dothinenteria. Some months ago, the patient to whom I refer occupied bed No. 7 of St. Bernard's Ward. She came into hospital with fever, general pains in the limbs, lumbar pains and headache; she complained of sleeplessness. The appearance of the tongue, copious diarrhoea accompanied by gurgling in the right iliac fossa, and finally an eruption of rosy lenticular spots, left no room for doubt as to the diagnosis. This woman, however, said that, four years previously, she had CONTAGION. 475 had precisely similar symptoms. At that time she was attended by my honorable and accomplished colleague Professor Rostan, in whose wards she remained for four months. The duration of the illness enables us to come to a probably correct conclusion as to its nature; but the circum- stance which removes all doubt on the point is the patient distinctly recol- lecting to have heard it stated by those around her at the time, that she had " typhoid fever." I have in my private practice met with an example of a person twice taking this disease. A girl, twelve years old, took doth- inenteria : the case was very severe, and the illness lasted fifty-seven days. In the following year, she had another serious attack of the same disease. The symptoms were quite as distinctively characteristic as on the first occa- sion ; and the duration of the disease was fifty days. Hooping-cough, which generally confers immunity for the future, may likewise occur more than once in the same subject. A girl of three and a half years of age, whom I had attended ten months previously for this dis- ease, again came under my care with hooping-cough, of which she had a second attack as severe as the first. These exceptional facts do not at all invalidate the general rule, that one attack of a contagious disease generally protects the individual from it for the future. It would appear that the virus or morbific matter, upon its entering the economy for the first time puts in motion all therein that is fermentable [tout ce qu'il peut y avoir de fermentescible], and so thoroughly destroys it, that the leaven-the contagion-when introduced again, finds nothing whereupon to exert its action. A similar immunity from the virus of contagious diseases is conferred by habitual exposure [accoutumance'] ; and also, immunity from infectious germs is bestowed by acclimation. In respect of both, however, the im- munity is more apparent than real. A European, for example, comes into a region where yellow fever is endemic: should he have the good fortune to sojourn there for a certain time without there being an epidemic of the disease, he will have acquired such immunity by his residence, that when the fever breaks out, his immunity will be equal to that of the indigenous inhabitants. This is what is alleged by those who hold that immunity is derived from acclimation. According to them, it is well known that the native inhabitants of a country enjoy so great a degree of immunity that even when they remove to another climate they may come back to their own locality without incurring any risk from contagion, although it might be supposed that during their absence they had lost part of their power of resisting it. The same remarks apply to marsh fevers. At our stations on the Senegal, where our troops, when they penetrate inland, are cruelly decimated by terrible attacks of pestilential fever, the indigenous negroes suffer very little in this way. So it is in our Algerian possessions: although very few Europeans escape the African fevers, the Arabs suffer less from them al- though they are not original inhabitants of the country: like our colonists and soldiers, they have emigrated to it, but having dwelt in it for seven or eight hundred years, the race has become acclimated. In the case of the Europeans, on the other hand, there has not yet been time for acclimation, for they have only been in Algiers since the conquest. It would appear then that acclimation in a certain number of cases con- fers absolute immunity from marsh fevers; but that in other cases the im- munity is only relative. The Arabs themselves take the disease, though in a less degree than Europeans. In the departments of France forming the old province of Sologne, where fevers always prevail, the inhabitants pay them a heavy tribute, as appears from the statistics drawn up by commis- 476 CONTAGION. sions of the recruiting department. Sologne, indeed, is never able to fur- nish its proper annual contingent to the conscription, so small is the num- ber of its really efficient men : nearly the whole population has a consti- tution deteriorated by the infectious miasmata to the influence of which they have been more or less subjected. Many have a bistre color of the skin, with engorged spleen and liver, the characteristics of marsh cachexia. To this fact, so opposed to their opinions, the reply made by the believers in immunity acquired by acclimation is, that the Bolognese enjoy a relative immunity. They say, let a Solognese and a Parisian go to live in a place where these fevers are at the time prevailing: the first will take a tertian or quartan ague, while the second will take a pernicious fever. When we come to consider the subject of marsh fever, we shall see, that the immu- nity about which I have now been speaking appears to belong to certain races, while there are other races which do not possess it, and are incapable of being acclimated. In respect of a contagious virus, it is not a question of immunity pro- duced by acclimation, but by habitual exposure [aecoutumance}. This is the explanation given of the fact, that nursing sisters and physicians can live in the midst of contagious diseases without contracting them. This fact has been compared with that immunity from poisoning by arsenic and opium respectively acquired by arsenic eaters and opium smokers-a new version of the more apocryphal story of King Mithridates. Poisonous doses of the most dangerous substances may be taken without harm by persons who have been long accustomed to their use in small doses. The alleged facts now mentioned in respect of acclimation and habitual exposure have not been, in my opinion, by any means demonstrated; and there are many other facts which are contradictory to them. From among the latter, I shall only cite one example. During the Crimean war, typhus made a relatively larger number of victims among the medical men than among the soldiers. Yet the medical men were placed in the conditions alleged to confer immunity, for, from the beginning of the epidemic, they were in contact with the sick. If there be any ground whatever for holding the opinion which I am now combating, it is, as I have just said, that the immunity spoken of is more apparent than real, except in some exceptional cases. This does not arise from the individuals possessing a natural capacity to resist morbid in- fluences, but upon their having acquired such a capacity at the cost of an attack of the disease, of which there remained neither trace nor recollec- tion, or of which the characteristic symptoms had been mistaken. Having spoken to you of variola sine variolis, of measles without eruption, and of "defaced" scarlatina [scarWine/nzste], you can understand that attacks of these exceedingly contagious diseases, by passing unnoticed, though con- ferring immunity from subsequent attacks, make it appear as if certain in- dividuals were originally exempt from the risk of contagion, whereas their exemption has been acquired by their having had the disease in question. Let me state the facts. Drs. Chervin, Louis, and I were sent to Spain to study yellow fever, when it was prevailing as an epidemic at Gibraltar.* You know with what rigorous precision my honorable colleague, Dr. Louis, was in the habit of observing patients and drawing up the reports of their cases: nothing could escape him. To enable him to draw up his.statistics satisfactorily, he wished to see the whole population. This was easily ac- complished at Gibraltar, where the inhabitants are few. We therefore saw * Chervin, Louis, Trousseau. Documents recueillis par la Commission Medi- cale Fran<?aise envoyee a Gibraltar. Paris, 1830. CONTAGION. 477 everybody; making diligent inquiry at the same time for those who had had yellow fever in the previous epidemics of 1804 and 1813. Upon inves- tigating the question, whether a previous attack had conferred the immunity which many seemed to enjoy, we found that among those who took the fever in 1828, there were only twenty-four persons who had previously had it. It is a remarkable fact that in reference to some of those whom the scourge spared, we were assured by persons who spoke from personal observation, that they had "imbibed a former epidemic with their mothers' milk," having had a mild attack of yellow fever which had lasted three or four days. Similarly mild cases we ourselves observed in the epidemic of 1828. For some days, the patients experienced a general feeling of discomfort, which did not prevent them, however, from following their usual occupa- tions. Under such circumstances, it is easy to understand how the disease might remain undiscovered. t In like manner, some persons owe their power to resist vaccination to their having had at some anterior period an exceedingly slight attack of distinct small-pox, characterized by a few pustules, to which no attention was paid, or by pustules confined to the arch of the palate, as occurred in a case which I met with ; or, again, the exemption may be conferred by the individuals having had small-pox during intra-uterine life. However mild, however distinct the attacks may have been, they suffice to confer im- munity: they not only render individuals incapable of taking small-pox, but they likewise incapacitate them from taking vaccina. I am not, however, disposed to deny that there are individuals who pos- sess an absolute immunity. To employ a comparison which I formerly used, I admit that in some individuals the soil is completely barren, and that in others it only enables the seed to germinate badly. On a former occasion, I cited examples to you of subjects upon whom neither exposure to the contagion of small-pox, nor even inoculation produced any effect: I know, also, that there are other individuals, who, although they have never been vaccinated, and have never had small-pox, yet when they do take small-pox, have it in a very modified form, which seems to demonstrate the existence of at least a relative immunity. The point upon which I wish to insist is, that absolute immunity is exceedingly rare.' One word more, gentlemen, on the transmission of germs. Some germs, such as that of syphilis, are transmitted by simple contact. That the contagion take effect, it is sufficient that the venereal virus be in contact with a mucous surface like that of the glans : it is not necessary that there should be any lesion, excoriation, or ulceration, which, however, if present would open a wide door for absorption. An often-repeated experiment has conclusively determined this fact. The experiment to which I refer consists in placing pus taken from a syphilitic ulcer under a watch-glass, and in contact with a healthy mucous membrane : the result is another ulcer-a specific chancre. Malignant pustule is also transmissible by simple contact. Shepherds often become affected by malignant pus- tule by skinning sheep which have died of sang de rate: the disease becomes developed in the eyelids, the cheeks, and other parts where there is no lesion of the integuments. I am aware that it has been said that in these cases the contagious pus had come in contact with some slight abra- sion of the skin ; but this is a mere supposition, for individuals the most scru- pulously careful of their persons, and who have affirmed that they had not the slightest abrasion anywhere, have taken the disease from sheep in the manner I have now described. It must be admitted, however, that trans- mission by simple contact is the rarest manner in which contagion is trans- mitted. 478 CONTAGION. The two more common ways are transmission by inoculation, and trans- mission by inhalation. In the first case, the virus is introduced into the system by a denuded surface, or by an artificial opening: to the latter mode, the use of the term inoculation is more properly restricted. Inocu- lation is the most certain manner of transmission ; for the virus being placed beneath the epidermis by the lancet, or brought into contact with a denuded surface, finds the open mouths of the absorbent vessels, and through them effects an entrance into the organism. The diseases of which I have been speaking, though contagious by simple contact, are in a much greater degree contagious by inoculation. Take small-pox, measles, and scarlatina. It is unnecessary to insist upon the inoculation of the matter of small-pox. As you are aware, for a long period variolous inoculation was the only means employed for pro- tecting the community from great epidemics of small-pox. At present, we hear nothing said about the inoculation of eruptive fevers through the blood ; but nevertheless, I ought to remind you that, although the experi- ments have often been negative in their results, we must concede an impor- tant place to the inoculation of the blood of small-pox patients succesfully performed by Luigi Sacco in 1849; and of the blood of persons having measles, likewise successfully performed by Home of Edinburgh in 1758; by Speranza of Milan in 1822; and by Michael of Katona, an account of whose experiments you will find in the "Gazette Medicale de Paris" for 1843. Finally, you are aware of the fact, upon which I have already suffi- ciently insisted, that syphilis may be transmitted by vaccination when the vaccine matter has been taken from a subject in whom syphilis is either active or latent.* Dr. Rollet, in a work published in 1861,f has repro- duced and supported the conclusions formerly arrived at by Dr. Viennois, his pupil.£ The cases reported by Drs. Rollet and Viennois leave no room for doubt as to the possibility of the transmission of syphilis by vac- cination. The two cases of M. Lecoq, military surgeon, still further confirm the statements of the physicians of Lyons, previously shown to be correct by facts adduced by MM. Waller, Gibert, and Hubner. From these data it is apparent, that under certain conditions, healthy individuals inocu- lated with the blood of persons affected with syphilis become affected with syphilis, which first shows itself by a chancre variable in form, and having a special form of induration. It is called by Dr. Rollet the vaccino-syph- ilitic chancre. In the second mode of transmission-transmission by inhalation-conta- gion takes place by the absorption of a virus or a miasm by the mucous surface of the respiratory passages, and, possibly also, by simple contact therewith. Here I must pause in my description, that I may make some explanatory remarks. This manner of transmission has been confounded with infection, but it much more nearly approaches transmission by direct contact, if indeed it be not identical with it. To explain the spread of certain diseases evidently contagious, it has been said, that the air is vitiated by effluvia from the sick, and has thus become infectious. In the ward of an hospital, contain- ing patients both with scarlatina and small-pox, other patients, occupying * See p. 113, of this translation : see also a communication made by Professor Trousseau to the Academy of Medicine in 1865, " De la Syphilis Vaccinate." f Rollet : Recherches Experimentales et Cliniques sur la Syphilis. Paris, 1861. j Viennois: Recherches sur le Chancre Primitif, et les Accidents Consecutifs produits par la Contagion de la Syphilis Secondaire. [7%£se] ; Paris, 1860. CONTAGION. 479 beds far removed from the latter, have taken scarlatina: it has then been said that the original scarlatina patients vitiated the air, that the second class of patients were infected by breathing the vitiated air-in the same way, for example, that individuals are infected, and take typhus, in the ambulances of armies. I do not think that this doctrine will bear the slightest examination. The air is not vitiated : it is simply contaminated. It serves in such a cage only as the vehicle by which are transmitted the volatile emanations from variolous and scarlatinous patients: it is not viti- ated any more than is the pus of a bubo serving as the vehicle of the germ of syphilis. Air and pus have each their own physical and chemical prop- erties: and in addition, the most delicate analysis and the best microscope can detect nothing more. The contaminated air serves as the vehicle for the virus of small-pox, just as the scabs from the pustules were in former times pounded down and dusted over the bread and butter intended for children subjected to inoculation, or introduced according to the Chinese fashion into the nostrils; or as threads soaked in variolous pus were used by early inoculators. Though in these cases, the contagion is transmitted in a more direct or at least in a more palpable manner, the transmission is similarly effected, when, by inhalation, the morbid principles transported in the air, come into contact with the nasal fossae and the bronchial tubes, penetrating to the remotest ramifications of the respiratory apparatus. Nevertheless, the third mode of transmission-that by inhalation-has been distinguished from the two others. Contagion, whether it be mediate or direct, is not infection. Both may originate in telluric or atmospheric influences; but there is, I repeat, this essential difference between them, that contagion transmits to a person in health morbid germs which have been developed in a diseased person, while this is not the case in respect of infection. In conclusion, let me recall to your recollection a fact which I have just mentioned, to the effect that contagious diseases, in passing from one to an- other animal species, lose their power of transmission: such is the case with hydrophobia. There are other contagious diseases which change their form in transmission. I dwelt on this fact at so much length when speaking to you of vaccina, eaux aux jambes, and cow-pox, saug de rate, charbon, and malignant pustule, that I need not resume the discussion.* * See page 96 and following pages of this volume. 0Z2ENA. 480 LECTURE XXIV. OZZEJNA. A very Common A ffection.-Must not be confounded with Fetor of the Mouth or Throat.-Fetor of Ozoena is altogether Peculiar.-Sometimes Depend- ent on Alteration of the Secretions.-Fetor of Inflammatory Secretions in some persons.- Constitutional Ozoena.-Symptoms.-Syphilitic Ozcena very frequent.- Ulceration of the Mucous Membrane: Necrosis.-Diseases of the Maxillary Sinus.-Topical Treatment is the most usual.- Constitu- tional Treatment is very useful in Syphilitic Ozcena: also of considerable benefit in Herpetic and Scrofulous Ozoena.-Powder for snuffing up the Nose.-Injections.- Treatment must be very patient and very varied. Gentlemen : You have repeatedly seen patients with ozsena [ozene, punaisie] in the clinical wards; and on several occasions I have directed your attention to the different causes of this cruel affettion. I very recently showed you a young girl who has had from infancy ozsena which I consid- ered to be herpetic; and almost at the same time, I had under treatment in the male wards a patient with syphilitic ozsena. Whenever the nasal secretions become fetid, we say that the patient has ozsena; but the causes of the fetor are so different, and the proper treat- ment so varied, that I cannot allow the occasion to pass without taking a short general view of the question. The horrible fetor of the breath which constitutes that which we call bug-stench [punaisie] is an affection so disgusting, and yet unfortunately so common, that you ought from the very beginning of your career to be acquainted with its causes and treatment. First of all, gentlemen, it is important not to confound the ozsena which proceeds from the nasal fossse with fetor of the breath caused by an affec- tion of the mouth and throat. In persons who have had frequent attacks of inflammatory sore throat there often remains submucous fistulse which secrete fetid pus, and wherein accumulate some of these sebaceous products, so often seen in the furrows of the tonsils, and which are ejected in the form of small, whitish, cheesy concretions, which when crushed emit an intoler- able stench. It is unnecessary for me to remind you of what takes place in cancerous affections of the pharynx, larynx, and upper part of the oesophagus. In persons whose breath is most free from taint, the normal secretion of the mucous membrane of the mouth, after accumulating during the night on the tongue and teeth, acquires a disagreeable odor. If there be an in- flamed condition of the gums and mouth, the secretion becomes more abun- dant and more fetid, and unless the requirements of the toilet are carefully carried out, this disagreeable state continues till the secretion is carried downwards at a repast. But should the individual have carious teeth, sup- puration in the centre of the caries, or around the diseased teeth, often occasions a fetor which cannot be got rid of, however great may be the attention given to the mouth. Let me also remark that in some individuals the secretions of the mouth OZtENA. 481 are naturally fetid, and incapable of being rendered otherwise by the most rigorous cleanliness. I need not remind you of an analogous condition of the feet, ears, and axillae. What I have now said will I think suffice to prevent you from falling into any confusion. It is important to avoid mistaking that fetor of the breath which proceeds from an affection of the throat or mouth for that which originates in the nasal fossae; but it is equally important to avoid the opposite error. Such mistakes, however, are always easily avoided. The simplest means of arriving at a correct diagnosis is to ask the patient to shut alternately the nose and mouth during expiration: when this is done, there is no difficulty in recognizing the source of the fetor. I ought, however, to add that the specific bad smell is chiefly met with in that form of ozaena called constitutional, and which is peculiarly allied to the scrofu- lous or herpetic diathesis. The two cases at present in the clinical wards give you a sufficiently cor- rect idea of the nature of the fetor met with in the different kinds of ozaena. In the young girl who has suffered from this disease from infancy, there is something in the smell which excites sickness: in the other patient, who is suffering from constitutional syphilis, the fetor is no doubt very great, but it is less nauseating. I shall not dwell longer, gentlemen, upon details the value of which you will be better able to appreciate at a more advanced period of your studies. Persons attacked with ozaena fortunately possess the privilege of not per- ceiving the bad smell, except in rare exceptional cases, as, for example, when the maxillary sinus is alone affected. The very disease of the mucous membrane which produces the ozaena destroys the sense of smell. It con- sequently happens that the affected individuals, without being aware of it, are frequently frightful sources of misery to those around them, who some- times, from politeness or pity, conceal their disgust. Sufferers from ozaena become incapable of distinguishing between good and bad odors; and at the same time lose the sense of taste, or, to speak more correctly, that portion of it which is associated with the sense of smell. I need not remind you, gentlemen, of the fact stated in all your books on physiology, that certain flavors are perceived by the smell, whilst most flavors are either not perceived at all, or only to a slight degree, when the nostrils are closed, or when the sense of smell is lost. Put lemon-juice into one glass, and into another water acidulated with acetic, sulphuric, hydro- chloric, or other acid, and you will find it impossible to distinguish the taste of lemon-juice from that of the other acid liquids, if you hold your nose in such a way as to close the nostrils. All secretions in contact with the atmosphere, unless renewed, become altered in composition. This alteration is more considerable in some per- sons than in others, in virtue of conditions which I find is rather difficult to describe, but which perhaps belong as much to the quality of the secre- tion, at the time of its formation, as to the special state of the secreting organ. In some persons the nasal secretions, like the pharyngeal, vaginal, and anal secretions, undergo rapid change, and acquire an excessive fetor, not perceptible in other individuals much less particular in the observances of the toilet. Sometimes ozjena is solely dependent upon the odor of the altered nasal secretion. When the mucous accumulation is removed from the nostrils in such cases, the breath becomes quite pure; but after some hours the fetor returns, if the mucous secretions have been allowed to reaccumulate in the VOL. I.-31 482 0Z2ENA. nasal fossae. It is obvious, that the remedy for an infirmity of this kind consists in blowing the nose frequently, and keeping it very clean. It appears then that in some persons it is normal for the secretions of the mucous membranes, like those of the skin, to be characterized by fetor. In such individuals, when the mucous membranes or the skin are affected by acute or chronic inflammation, this normal fetor becomes very greatly increased. You know how easily, particularly in fat persons, a bad smell is produced by chafing under the mammae, in the folds of the thighs, or around the anus; and that sometimes there is no preventing this by the most scrupulous attention to cleanliness. So it is, as you know, in inflam- matory affections of mucous membranes; for you must have been often struck with the fetor of gonorrhoeal matter in some individuals. The fetor lasts as long as the acute stage of the inflammation ; and in some persons, even after the inflammation has passed into the chronic stage, the inflam- matory secretions continue to emit an intolerable smell, however brief may be the time during which they are allowed to remain in the situation in ■which they were secreted. If the inflammation of the mucous membrane is of a special character, the secretion may be fetid from the very first moment of its formation. It is necessary, gentlemen, to enter into these details, to enable you to understand the history of ozaena. There are many persons, who, when they have coryza, discharge mucous secretions possessing an exceedingly dis- agreeable odor; it is not, however, the odor of constitutional, but of what may be called the first stage of accidental ozaena. Should the coryza be- come chronic, the secretion will undergo change whilst remaining in the nasal fossae, and the fetor may resemble that which is met with in certain specific inflammatory affections of the pituitary mucous membrane. The form of the disease designated constitutional-a term, however, which I do not justify-is not in general met with till after the years of childhood, even when there have existed from birth some of these anatomical lesions of which I shall afterwards speak, and which almost invariably lead to ozaena. The malady seldom begins to make its appearance in subjects under four or five years of age; but towards puberty it assumes considerable proportions, and continues considerable during adult years, decreasing, but not entirely disappearing at a more advanced period of life. This form of ozaena is characterized by a repulsive sickly smell, bearing no resemblance to any other smell; generally, the nasal secretions are purulent, sometimes they desiccate, forming crusts moulded in the passages, and when this is the case, they are almost always mixed with a little blood, if an effort has been required to expel them. There is often a very abundant purulent dis- charge; and it is not in such instances that the stench is most disagreeable, unless the ozaena proceed from disease of the maxillary sinus, from which, the pus having therein accumulated, may come in gushes, consequent upon certain movements of the patient. Upon examining the interior of the nasal fossae by the aid of a small speculum, some redness of the mucous membrane is nearly always found. Deformity of the nose, from flattening of the root, is pretty frequently observed in ozaena. It has for that reason been assigned as a cause of the disease: it has been supposed that the consequent structure of the nasal fossae prevented the evacuation of the mucous secretions, which become altered from being long pent up. Bear in mind what occurs in syphilitic ozaena of the adult during the course of which fetor may exist, and in fact generally does exist, without there being any disease of the bones or de- formity of the nasal fossae: bear in mind also, that in the majority of adults attacked by ozaena there is no deformity of the nose. The natural infer- OZJENA. 483 ence, therefore, is that the flattening of the root of the nose and the ozsena both proceed from the same cause-that is, from chronic inflammation and ulceration of the mucous membrane, with consecutive necrosis of the vomer and some portions of the ethmoid bone. Moreover, persons are often met with who have nostrils so exceedingly narrow that the air does not pass through them in quantity sufficient for the requirements of respiration, and in whom nevertheless the nasal secre- tions are always inodorous. There are other and rarer cases, in which there 'is no deformity of the root of the nose, in which the nasal secretions present no unusual appearance, and in which neither is there pain in the head nor tension of the upper jaw to indicate a state of acute or chronic inflammation. The mucous membrane in these cases is also without any of the characteristics of in- flammatory action. Again, when there is nothing to lead one to suppose that there is inflam- mation of the pituitary membrane, or necrosis of the bones-when the individual attacked by ozsena has the conditions of perfect health-we find ourselves forced to admit that there is a peculiar fetor of the nasal secre- tion, like that observed in the feet of some people: this is the form of the disease to which the term constitutional ozsena ought to be restricted. To follow out the comparison : we should not be justified in confounding the bad smell which proceeds from the feet of those who neglect necessary ab- lution and have no skin disease, with the disagreeable odor so often ob- served in the feet of patients suffering from chronic eczema of the feet, and particularly from the sequela of cutaneous inflammation, such as are seen between the toes in the course of venereal diseases. Alongside of this kind of ozama, which is really constitutional, we must place that other form of the disease which depends upon the herpetic dia- thesis, and which is usually seen along with the ophthalmia called scrofu- lous, and swelling of the upper lip. It must not be supposed that every herpetic affection of the mucous membrane of the nasal fossje gives rise to ozcena any more than that herpetic affections of certain parts of the body are necessarily accompanied by fetor: but just as eczema of the feet and vulva produce secretions of most disgusting odor in some persons, so does chronic eczema of the mucous membrane of the nasal fosste produce in some patients a secretion emitting a most revolting smell. The most frequent cause of ozsena is undoubtedly syphilis. When the system is contaminated by the venereal disease, coryza is very common, and although, in the majority of cases, it does not cause fetor of the breath, yet it gives rise to it in the same way as do herpes and scrofula in some persons. But however great the fetor may be in such cases, it never equals that of constitutional oztena. Syphilitic ozama gives rise to ulceration and necrosis, and is the severest form of the disease. A membrane so delicate as the pituitary membrane cannot long with impunity be the seat of inflammation: ulcerations frequently follow ; and Dr. Cazenave of Bordeaux, to whom we are indebted for interesting re- searches on the subject now before us, has seen ulcerations even on the floor of the nasal fossse: by using a speculum, similar to that employed for the exploration of the auditory passage, ulcerations can easily be detected upon the septum and those parts of the nasal passages nearest to the opening of the nostrils. These ulcerations become a new cause of ozeena in a way which I shall now explain. Whatever may be the cause of the ulceration, the submucous cellular tissue is easily invaded by it, and the bone itself soon becomes affected. From the very first moment of the existence of this lesion, it becomes a 484 0Z2ENA. new cause of ozrena; and even when the original disease is quite cured, the fetor continues till the necrosed portion of the bone has exfoliated, or been removed by surgical interference. Although the smell is much less horrible when there is no necrosis, the infirmity is still a disgusting one, for which patients often seek treatment at our hands. When the arch of the palate, the nasal process of the superior maxilla, the vomer, and the nasal bones are involved in the necrosis-when there is actual destruction of the bones of the nose-the ichorous suppurative secre- tion is profuse, and the fetor is shocking, although it does not possess the peculiar odor of constitutional ozama. Your surgical professors have taught you that the necrosis which follows gunshot wounds, fractures of the bones of the face, and sometimes even that which depends on the existence of polypi, may produce ozsena. But diseases of the maxillary antrum are still more frequent causes. I was recently consulted by a man of forty years of age, who, with the exception of the affection now under examination, was in good health: he complained of ozsena, which he said had been for a long time the torment of his life. He was standing: I caused him to throw his head backwards, and shut his mouth, so as to be compelled to breathe through the nostrils: to my sur- prise, I could detect no fetor in the breath. He then told me that he could produce the disgusting smell at pleasure; and sitting down, with the head inclined very much downwards, he discharged into his pocket-hand- kerchief a large quantity of pus, which exhaled an intolerable stench in my consulting-room. I have, gentlemen, but imperfectly sketched the picture of ozsena. I have only attempted to give you a summary view of a common disease, which is of a rebellious character, and not very well understood: I am now particularly anxious to point out to you some of the therapeutic means by which we sometimes cure, and often palliate this cruel infirmity. First of all, let it be distinctly understood, that we can do nothing, or next to nothing, for ozsena dependent on necrosis: it is only too evident that we can exercise no control over such a disease: the dead bone may become detached in whole or in part, and yet the odor remain as long as there remains a fragment of necrosed bone. You only require to glance at the skeleton of the nasal fossae to form an idea of the difficulty of expelling some of the portions of the dead bone. When the necrosis is very exten- sive, the ozaena may last for a long series of years, surgery generally being unable to afford any relief. At the end of May, 1863, I saw at the Hotel du Louvre, in consultation with my honorable colleagues Hrs. Higgings and Shrimpton, a young Eng- lish officer of the Indian army, who had for a long time been suffering from syphilitic ozaena. He had had, on the preceding evening, a sudden and terrible suffocative attack, caused by the presence in the posterior nares of a foreign body, which had subsequently fallen into the throat. In the midst of his suffocative convulsions, he seized with his fingers, and finally drew forth a large irregularly shaped and rough-edged piece-about a fourth part-of the ethmoid bone. On the same day, cerebral symptoms supervened, under which he died within twenty-four hours. It is probable that there were suppuration of the meninges of the brain, at the points corresponding to the cribriform plate of the ethmoid bone. You perceive, gentlemen, that when there exists necrosis of this description, expulsion of the dead bone is almost impossible, and exfoliation cafi. only take place in small splinters, and therefore very slowly. Ulceration or necrosis of the walls of the antrum, or chronic inflamma- OZJENA. 485 tion of the mucous membrane which lines it, will also produce a kind of ozaena for which we can do little. In the majority of such cases, the only means of cure is to make an opening into the antrum, through the superior dental arch, and thereby directly introduce therapeutic agents. In all cases in which we can direct our treatment to the cause of the inflammation of the pituitary membrane, and in which there is no affection of the bones, the cure is easy : thus, for example, in syphilitic coryza without ulceration, mercurials, and the iodide of potassium are generally efficacious, in the same way that they cure chronic syphilitic inflammations of the pharynx and larynx: but when the ozaena is herpetic, we have no longer specific remedies as in syphilis, and then the cure is often unattainable. Some slight benefit may be derived from preparations of arsenic, iodine, and sulphur; but it is upon topical treatment that we must principally rely. It is still more difficult to obtain favorable results from treatment, when we have to contend against the scrofulous diathesis; and although we may to some extent modify the state of the system by placing the patient under good hygienic conditions, and giving him certain medicines (the triviality and insufficiency of which you know), it is necessary to trust almost exclusively to remedies which can be applied in a direct manner to the diseased mucous membrane. It is, therefore, upon the topical treatment, that I am now going chiefly to insist: it is the kind of treatment which will render you the most signal service. Powders inspired by the nose (as snuff is taken), the direct application of caustic to the ulcerated parts, and injections of various kinds, are the means generally employed; and as they are those which have proved most useful in my practice, I feel that I am entitled to recommend them. Do what you may, it is not easy to accomplish a cure, nor can you ever obtain a cure within a short period. Still, though the means generally employed are imperfect, and not so efficacious as we should desire, we can achieve rela- tively good results upon which to congratulate ourselves. There are four powders which I chiefly make use of: I shall now give you the formulae by which to prepare them. No. I. Subnitrate of bismuth, . Venetian talc, of each 15 grammes. [232 grains.] No. II. Carbonate of potash, ... 2 grammes. Sugar in fine powder, . . .15 " [30 grains ] '232 grains.] No. III. White precipitate, . . .25 centigrammes [3| grains ] Sugar in fine powder, . . .15 grammes. [232 grains.] No. IV. Red precipitate, . . . .25 centigrammes. [3| grains.] Sugar in fine powder, . . . 15 grammes. [232 grains.] No topical application can be of the least use unless, before its employ- ment, the nasal fossae have been cleansed by the patient, causing cold or tepid water to pass through them. Before the topical medication is pro- ceeded with, the mucous accumulations and the crusts which cover the pituitary membrane must be removed. I at once begin by employing the mercurial powders. I direct the patient to draw up vigorously a pinch of the powder through each nostril, so as to cause it to penetrate into most of the turnings and hollows of the nose. This proceeding ought to be repeated twice or thrice a day, the frequency being regulated by the amount of irritation produced. Generally speaking, prac- titioners are not sufficiently upon their guard in respect of the powerfully irritant action of white and red precipitate. Both of these agents, so power- fully efficacious in the treatment of chronic ophthalmia, and diseases of the skin and mucous membranes, are frequently abandoned just because their 486 OZJENA. irritant action has proved greater than had been expected. The remedy is charged with producing a bad effect, for which the physician alone is to blame. You must remember, therefore, gentlemen, when you prescribe these mercurial powders, to be on the watch for the irritation which they may excite in the nasal fossse; and you must order only a small number of inspirations of them in the course of a day, likewise directing them to be continued only for a few days. There will be a tendency to push too far the use of these remedies in ozsena, from the beneficial results which they produce being as rapid as they are unlocked for. It is no exaggeration to say that in some patients the fetor disappears a few hours after the powder has been snuffed up for the first time: this result is temporary, I admit, but it is positive, however in- explicable it may be. The effect produced at least proves that the mercu- rial powders possess the power of modifying the condition of the diseased mucous membrane; and, at the same time, it invites us to give the prefer- ence to the topical employment of mercury in the treatment of ozsena, in the form of powder, in the manner I have just described; or in the liquid form, according to a plan which I shall forthwith mention. Though it is necessary to be guarded in the use of the mercurial powders, no such caution is required in employing the mixture of bismuth and talc: patients may snuff it up as often, and in as large quantities, as they please. One might say that the bismuth and talc powder was inert, were an opinion to be formed by the slight amount of irritation produced by applying it; but it is one of the remedial agents on which I place most reliance in the treatment of ozaena, and to which I revert more willingly than to others, just because it may be so freely applied without occasioning any bad con- sequences. The chlorate of potash, to which Dr. Henri Saint-Arnoult has given a not altogether unmerited reputation, also renders real service: like the mer- curial powders, it possesses the great advantage of causing the smell to dis- appear whilst it is being used. Were the action of this remedy only that of a disinfectant, it would unquestionably deserve to be recommended ; but it merits recommendation on another ground, and that is, that like mercury, it modifies the state of the mucous membrane. You have seen, gentlemen, with what rapidity topical treatment seems to have accomplished a cure in the young girl, our patient in St. Bernard's Ward. Looking to the results, it might appear that she is already cured, but it is not so; and, as I shall tell you immediately, there are few affec- tions in which both the sufferer and his physician require to exercise more patience than ozsena. In adults, as their obedience to instructions may be counted on, the in- spiration of the powder, though insufficient, nevertheless render eminent service ; but in children, this method is almost useless, and in them we must employ injections, as the almost only available treatment, whereas, in adults, they are merely the complement of other measures. The following are the injections which I most frequently have recourse to: No. I. Eau phagedenique, . . . 200 grammes. [§vj and jij.] [Shake the bottle well before using the injection, so that the precipitate may be thoroughly mixed with the fluid.]* No. II. Chlorate of potash, ..... 2 grammes. Distilled water, ...... 200 " No. III. Nitrate of silver, ...... 5 grammes. Distilled water, ...... 100 " * Eau phagedenique. See page 441 of this volume. OZJENA. 487 No. IV. Sulphate of copper [or zinc], ... 5 grammes. Distilled water, 100 " There is a very important practical remark which I have to make in relation to these injections. The pituitary mucous membrane is much more sensitive than is generally supposed. It is necessary, therefore, on beginning injections, to use very weak solutions. It often happens that a solution of 5 centigrammes [f of a grain] of nitrate of silver, sulphate of copper, sulphate of zinc, or corrosive sublimate, in 100 grammes [3 fl. oz. and 1 drachm] of distilled water, is not well borne. Let me add, that this extreme sensitiveness quickly disappears, and that very soon a tolerance for a stronger solution is attained. The solution, however, ought never to be very strong, and should always be proportionate to the sensibility of each patient. The injections require to be used for several days in succession-twice, thrice, or four times a day, after which the powders ought to be resumed : then, by and by, the injections ought to be resumed, their number being diminished or increased from day to day, in accordance with the amount of irritation which they excite in the pituitary membrane, and the curative results which are obtained. In so obstinate an affection as ozsena, it is easy to see that remedial measures must be continued for a long time ; and if the physician, pleased with apparent success, abruptly interrupt the treatment, the disease will at once relapse. Often, we may exercise the greatest patience, and modify our plan of treatment in many ways, without succeeding in obtaining a radical cure. The proper plan, then, is at once, uninterruptedly, and repeatedly in succession, to apply the remedies. When the fetor has been absent for six weeks or two months, the severity of the treatment may be relaxed by reducing the number of the daily nasal inspirations of powder, or injec- tions. Should the improved state of matters continue, the remedies may then be applied only once in two days, afterwards once in three days, and finally, for some months longer, at intervals of four days. There is another very important practical point to which I wish to direct your attention. At the menstrual periods, there is generally a great in- crease in the severity of the symptoms, irrespective of treatment. Even when the plan of medication is directed in the best possible manner, the fetor generally returns somewhat during menstruation. This also occurs under the influence of any cause which excites inflammation of the pitui- tary membrane. It is a rule which never ought to be deviated from, to carry out the treatment in all its rigor when the patient is in the special conditions I have mentioned. Even when the symptoms of ozsena have been absent for a long time, the practical precept now laid down must not be forgotten. However beneficially potent the inspirations of the powders and the injections may be, they are not in themselves sufficient even as topical remedies. Dr. Cazenave of Bordeaux long ago insisted on the necessity of applying modifying agents to the surface of the nasal fossae and other accessible situations, by means of elastic bougies or rigid sounds adapted to the form of the parts, instruments in fact analogous to those employed in treating diseases of the urethra, bladder, and uterus. Although topical remedies hold the chief place in the treatment of non- syphilitic ozsena, it would be a great mistake to omit general treatment. Cod-liver oil taken for fifteen consecutive days in every month, and con- tinued for a long time, is sometimes very useful. The tincture of iodine administered over a period of several months, twice or thrice a day, at 488 STRIDULOUS LARYNGITIS. meals, in a dose of from 5 to 20 drops, often produces exceedingly benefi- cial results in constitutional ozama.* Arsenical preparations, perseveringly continued, as is usual in treating the herpetic diathesis, are still more pow- erful adjuvants to the topical medication. It is hardly necessary to say, that in syphilitic ozsena, mercurial prepara- tions and the iodide of potassium take a place in the treatment even more important than local applications. Necrosis, polypi, and the different diseases of the antrum of the maxilla, being rather within the sphere of the surgeon than of the physician, I shall not here discuss. Gentlemen, I must not conlude without repeating, that ozsena is one of the most difficult diseases to cure ; but that it is also one of those which it is very easy to palliate, provided reliance can be placed on the cleanliness, docility, and patience of the sufferer, and provided also, that there is a similar exercise of patience on the part of the physician. LECTURE XXV. STRIDULOUS LARYNGITIS, OR FALSE CROUP. Long confounded with Pseudo-membranous Croup.-Differs essentially from that disease in its nature, manner of invasion, progress, and complica- tions.- Croupy [croupale] Cough presents characters very different from those of True Croup.-False Croup is not a dangerous disease; but still, in some very rare cases, it has caused death.-The prognosis is serious when the laryngeal affection is the forerunner of peri-pneumonic catarrh. -In the majority of cases, the Treatment ought to be Expectant. Gentlemen : When lecturing on diphtheria, I intentionally omitted the consideration of the differentia] diagnosis of true and false croup,f because it seemed more in place to speak of it when discussing the latter affection. The manner of establishing the differential diagnosis is a corollary to the remarks which I propose to make to-day on stridulous laryngitis [laryngite striduleuse']. A perusal of the work on croup by Home of leaves a con- viction on the mind of the reader, that the author was pretty much in that deplorable state of confusion which, at the time he wrote, had been intro- duced both into the scientific and practical discussion of the subject. It is evident that he describes under the same name two essentially distinct dis- eases ; and that though he may sometimes have had to do with pseudo- membranous laryngitis, the majority of the cases he reports are cases of false croup. The same confusion pervaded all the writings published on croup from the time of Home to the appearance of Bretonneau's treatise on diphtheria. This confusion even pervaded the memoirs submitted to the * The tincture of iodine of the French Codex is simply a solution of about one gramme [15J grains] of iodine in twelve grammes [four fluid drachms] of alcohol. -Translator t For the lectures on Diphtheria, see pp 335-434 of this volume. | Home : Inquiry into the Nature and Cure of the Croup. Edinburgh, 1765. STRIDULOUS LARYNGITIS. 489 Concours in 1812-even the memoirs of Vieusseux, Jurine, and Albers of Bremen, which were honorably mentioned by the Academy. Royer-Col- lard, the reporter of the commission appointed to examine these works, did not avoid it; and his report, in other respects remarkably good, shows that when he wrote, the notions of Home were still in the ascendant. Indeed, the light of truth did not shine upon this chaos of opinion till Bretonneau established with marvellous lucidity the characters which distinguish from each other the two diseases, showing them to be essentially different in their nature, lesions, symptoms, and relative gravity. The one, true croup, is almost always fatal, unless the treatment be prompt and proper ; but the other, false croup, is not a dangerous disease, save in exceptional cases. Stridulous laryngitis, or false croup, is a very common affection. Every physician, in the course even of a very short practice, has often been sud- denly summoned in haste to children said to be suffering from " croup." Although the matter has now been pretty generally explained, the error I mention is still committed every day. This explains how it is, that some practitioners congratulate themselves upon their treatment of croup, and boast of an amount of success which would astonish us, if we could suppose that the cases cured were undoubtedly cases of pseudo-membranous laryn- gitis. Persons who allege that they have cured a great many cases of croup with extraordinary rapidity-in a few hours for example-by emetics, blis- ters, and leeches, or other means, fall into the very confusion of ideas to which I have now been directing your attention: they allow themselves to be deceived by a symptom, to which they have attached too much impor- tance, and of which they have not perceived the real characters: they, in fact, allow themselves to be misled by a cough very improperly called croupy. So exclusively has their attention been occupied with this cough, that they have taken no account of the antecedent history, or at least have paid insufficient attention to the progress of the symptoms-they have not examined the pharynx with that minuteness which was necessary to ascer- tain whether any diphtheritic exudation existed. Notwithstanding the frequency of stridulous laryngitis, it is a disease which is rarely met with in our hospitals, and I have only had one case in my wards since I occupied the chair of clinical medicine. The reason of this you can quite understand. The disease is, in the first place, peculiar to infants and children under two years of age; and, save in a few excep- tional cases received into the nursery ward, children so young are not ad- mitted into the Hotel-Dieu, which by rights is exclusively an hospital for adults. In the second place, from the sudden manner in which false croup declares itself, and from the rapidity with which it yields, it is very unusual for children who are attacked by it to be brought to the hospitals. I shall therefore only recapitulate the particulars of the one case which we have had in our wards; but I should be leaving the subject of croup in an un- finished state, were I not to take this opportunity of speaking to you of the differential diagnosis of croup and false croup, for the latter affection, though rare in hospitals, is very common in private practice. What then are the characteristic symptoms of stridulous laryngitis? A child between two and five years of age-the age, observe, at which true croup is also most common-is suddenly seized in the middle of the night-say at eleven o'clock, at midnight, or at one in the morning-with a paroxysm of difficult breathing. He wakes up in a start, in a state of considerable febrile excitement: he has a cough, which is hoarse and very frequent, as well as strong and noisy: respiration is panting, short, and ac- companied, during inspiration, by a sharp sound-by a shrill, jarring laryn- geal whistle. The voice is altered in tone: during the paroxysms, it is 490 STRIDULOUS LARYNGITIS. altogether gone, and in the intervals, is harsh and hoarse. In true croup, there is very seldom complete loss of voice: this is an important point to which I shall return. The symptoms are much more urgent than those which characterize the commencement of an attack of laryngeal diphtheria. Sometimes, the dyspnoea and anxiety are as great as in the last stage of pseudo-membranous laryngeal sore throat; the countenance is turgid, and the eyes express pro- found terror: the character of the cough, voice, and laryngeal whistling are such as to strike terror in families, and frighten even physicians themselves. However, in half an hour, an hour, or in two or three hours, the frightful crisis has terminated: the child becomes calm, sleep returns, his pulse is less rapid, and his skin is somewhat moist: when he wakes, his cough is still croupy, but it is more moist, and in the morning, it is still more catar- rhal ; respiration is less whistling, and the voice has nearly regained its natural tone. The symptoms generally recur for several nights in succes- sion, but with diminished severity in each following attack. The patient has usually good days, there being an almost total absence of fever, and general discomfort: the cough continues, but is moist, and much less rough. Upon questioning the relations as to the history of the attack, you are told, that the child went to bed in perfect health, and fell into a tranquil sleep. You will sometimes be informed that the child had been complain- ing a little for some days prior to the attack: that he had taken cold, but was going about, eating, and playing as usual: that he had retained his cheerfulness, and followed his accustomed routine: in a word, that there was no change whatever in his habits. If you inspect the throat with the most minute care, you will be unable to see any false membrane. The mucous membrane is sometimes red : the tonsils may be swollen ; but on examining the cervical and submaxillary regions, you will find that there is no swelling of the glands. It is in this sudden manner, and with these symptoms, apparently more alarming than those of croup, that false croup generally declares itself, the disease which you cure, or I ought rather to say which cures itself; for what- ever is done, however inopportune and irrational the medical intervention may be, it is seldom capable of rendering the affection dangerous, so little is there in its nature of a serious character. However, gentlemen, there are circumstances which limit this favorable prognosis. Stridulous laryngitis supervenes at the onset, and during the course of certain diseases; so that it is obvious, that under certain circum- stances, you may have to do with a peculiarly modified affection. When speaking of eruptive fevers, I called your attention to the fact that it is common, during the invasion period of measles, when the nasal, ocular, and bronchial mucous membranes become affected, to see the larynx become similarly involved; and I also pointed out that in children, during the first two, three, or four days, before the eruption has come out on the skin, all the symptoms of stridulous laryngitis are sometimes met with. In small-pox, which is also generally accompanied by sore throat involving both the pharynx and the larynx, the occurrence of false croup is not un- usual, though it is not so common as in measles. Gentlemen, false croup may be the starting-point of one of the most serious diseases of childhood, catarrhal pneumonia, capillary catarrh, which, according to my experience, is more formidable than croup itself. I have long ago explained to you my views on this subject, and I shall again do so, when I come to speak of the pneumonia of children. Here, gentlemen, I ought to recapitulate the history of the case to which I alluded at the beginning of this lecture. From it you will learn a fact,. STRIDULOUS LARYNGITIS. 491 which I shall afterwards have to state, that tracheotomy may be useful iu false croup; and it will likewise show you, that false croup may be the starting-point of fatal pneumonia. The following are the particulars of the case to which I refer. In January, 1863, a female infant was received into my wards. The interne on duty observed that she had very great difficulty in breathing, but no suffocative paroxysms. According to the statement of the mother, the dyspnoea had increased rapidly within the last few hours. The child had had cough for some days: upon examining the chest, however, no sign of pleurisy or bronchitis was discovered. Inspiration was very labored, and somewhat whistling: the cry was hoarse and muffled: the obstacle to respiration was unquestionably situated in the larynx. There was no false membrane in the back part of the mouth, nor had the child thrown off any: still, though it was only a case of false croup, M. Dumontpallier, without hesitation, immediately performed tracheotomy, as it was necessary to prevent suffocation. The operation was easily accomplished; and the patient breathed freely as soon as the tube was fixed. The infant passed a good night; and next morning I found that there were no morbid sounds in the chest. The infant's appearance was good; and she took the breast with satisfaction. On the third day after the operation, an attempt was made to withdraw the canula, but asphyxia being threatened, it was instantly abandoned. The larynx, therefore, was evidently still obstructed, although the infant had ejected by the canula nothing more than pinkish muco-puriform sputa, such as are seen in the bronchitis of measles. On the following days, we renewed our endeavors to remove the canula; but each time we took it out, it was necessary to replace it with the utmost possible haste, as no air traversed the larynx. Ten days after the operation, the infant still had a favorable appearance, and continued to take the breast: she was in good spirits, her flesh had become firm, and she was not getting thinner: but the canula had been kept constantly in the trachea. The lips of the wound were in a very good state. On the eleventh day after the operation, I was told that the patient had been very restless during the night. The pulse was quick, and the skin burning. The infant frequently took the breast, but immediately gave up her hold of it. Fine mucous rales were heard over the entire thoracic region. The fever, restlessness, and physical signs of general bronchitis caused me to form an unfavorable prognosis: very probably, small masses of pulmonary hepatization already existed. An attempt was made to re- move the canula, but it was fruitless, as the air did not traverse the trachea in sufficient quantity. On the fourteenth day, the little patient, at the morning visit, lay motionless on the bed, and presented the signs of peripneumonic asphyxia. The pupils were very much dilated; sputa no longer came up through the canula: the pulse was too rapid to be counted: death, preceded by some convulsive movements, then closed the scene. The autopsy showed that no pseudo-membranous 'deposit existed on any part of the respiratory passages; but the glosso-epiglottidean folds were red, and the aryteno-epiglottidean folds were cedematous. The opening of the glottis seemed to be almost entirely closed by the swollen, injected mucous membrane. The mucous membrane of the larynx, which was also injected, was the seat of an inflammatory vascularity. Similar indications of inflammation were seen on the mucous membrane of the trachea and bronchi. Several pulmonary lobules, particularly on the left side, were inflamed and purulent: when cut, they yielded, on slight pressure, small 492 STRIDULOUS LARYNGITIS. drops of pus: at the inflamed points, the lung had the appearance of a sponge filled with purulent matter. There was likewise empyema on the left side, which perhaps had had its starting-point in the nuclei of puru- lent hepatization observed on the surface of the lung. In this case, the pneumonia and pleurisy supervened during the last few days of life, the morbid changes advancing rapidly to the formation of pus. Without any of the complications of an eruptive fever or pulmonary inflammation, false croup sometimes causes death ; although generally, I may say very nearly always, it is not a dangerous affection. Fatal cases are quite exceptional; but you must recollect that they sometimes occur. Here is a case in point. In 1834,1 was summoned in haste to see a pupil at the College of Juilly, who, I was told, was dying. The lad was thirteen years of age. On the evening before his attack, he was quite well. In the morning, on awak- ing, he was suddenly seized with a frightful attack of dyspnoea : he got up, however, and ran to the room of the prefect of the studies. Respiration was exceedingly embarrassed : there was a hoarse croupy cough ; the voice was harsh and small: inspiration produced a noisy whistling. The medi- cal attendant of the college, who was immediately sent for, was with good cause alarmed at the state of the patient, and at once sent off one of the masters to fetch me. I started forthwith: and in four hours reached the patient, who had just expired. The circumstances seemed to me to be too extraordinary to allow any means to be neglected to discover the cause of the sudden catastrophe. I removed with the greatest care the larynx and trachea and took them to my colleague's house, where we examined them. We found that it was only a case of false croup. There was a good deal of swelling of the vocal cords, redness of the laryngeal mucous mem- brane, and a little swelling of the aryteno-epigottidean folds: on one of the vocal cords, there was a slight membranous concretion, possesssing, how- ever, none of the characters of diphtheritic false membrane, and depending upon a very intense inflammatory sore throat. Patients, therefore, may die from stridulous laryngitis; but let me again repeat that such cases are exceedingly rare. During my long practice, I can only remember to have met with three fatal cases. Still, gentlemen, I say, be reserved in your prognosis, notwithstanding the extreme benignity of the disease: in particular, be reserved, not so much because in a few very exceptional cases, the issue has been fatal, but because false croup may be the forerunner of catarrhal pneumonia, a disease which seldom spares those it seizes. I may say that I have had some experience in croupy affections, and though I am perfectly aware of the immense odds which the patient has in his favor, I cannot exclude from my mind a cer- tain amount of dread that I may by and by have to do with that terrible disease of which false croup is only the first symptom. As I began by stating, the differential diagnosis of true and false croup is a logical deduction from the facts which I have laid before you. Still, it sometimes happens, that to form a diagnosis is embarrassing: this is the case when stridulous occurs in persons affected with common membranous sore throat, and when diphtheria begins by simultaneously seizing larynx and pharynx. You well know, that in the majority of cases, the membranous affection commences in the pharynx, and is thence propagated to the larynx; some- times, however, though not frequently, the attack all at once begins with croup. When this occurs, it is very difficult to determine whether there is pseudo-membranous or simple laryngitis ; but the progress of the symptoms may furnish presumptive evidence of the nature of the disease we have to STRIDULOUS LARYNGITIS. 493 deal with. Notwithstanding what has been alleged to the contrary, even in cases of sudden croup, the characteristic symptoms of the membranous affection are in general slowly developed: observe, I say, generally and not always: on the contrary, the characteristic symptoms of false croup quickly declare themselves. False croup sets in abruptly, and from the very first the symptoms are alarming; but they decrease in severity. In true croup, the invasion is less abrupt, but the symptoms gradually go on increasing in severity. Suppose, for example, two children, one of whom has had a hoarse voice for two or three days, and a suspicious cough for forty-eight hours; the other, a sudden attack during the previous night of difficult breathing, accompanied by whistling inspiration, and a ringing croupy cough : of the two, the former is the most seriously ill; for he has true, while the latter has false croup. Diphtheritic inflammation, in fact, takes a certain time to evolve; two or three days elapse before it attains its maximum intensity. At first, the irritation which it causes in the parts about to be covered with false membrane is very slight, and only excites some fits of coughing: the discomfort in breathing, which in the first instance is produced by the swelling of the vocal cords, only shows itself by a moderate degree of op- pression. It is not when the inflammation of the mucous membrane of the larynx is greatest, but when the thick diphtheritic membranous deposit interposes a physical obstacle to the passage of air, that there is most diffi- culty in breathing. Acute simple inflammation of the larynx proceeds otherwise: it almost at once produces swelling of the mucous membrane : in from half an hour to an hour, or in two hours at the most, this swelling is at its maximum, and the consequent sudden stricture of the opening of the glottis causes the suffocative seizures which characterize false croup. It is a remarkable fact that the suffocative seizures occur during the night, and very seldom in the daytime. To put it still more clearly, they take the patient by surprise when he is asleep, and not when he is awake. Stridulous laryngitis not only differs from true croup in mode of invasion and progress of symptoms, but also, and even more, in the character of the cough called croupy, the semeiological value of which we have still to ex- amine. On this subject, gentlemen, let me give you the result of my long experience: it is not infallible-it is very far from being so-and so fre- quently does it deceive me, that I warn you not to be astonished should you be sometimes similarly misled; nevertheless, my experience has taught me things which it may be useful for you to know. In very young children, however slightly the mucous membrane of the larynx is inflamed-and consequently swollen-the cough has a hoarse character, inspiration is whistling, and the voice is greatly altered. This is sometimes observed in simple catarrhal affections. The vocal cords are exceedingly sensitive to the mucus which falls on them, and even the air which traverses the glottis ; in a word, the mucous membrane of the larynx, naturally of an irritable, excitable character, is in a state of exceedingly increased irritability. There will be incessant cough, and in the space of one minute the patient will have from fifteen to twenty paroxysms. The cough, therefore, which has received the name of croupy, is in very young children the consequence of acute inflammation of the mucous membrane of the larynx ; or, to be more precise, it is the expression of the existence of simple acute inflammation. Diphtheritic inflammation, however, is not simple and acute: at first, it is very slight, and very much more superficial than simple laryngitis. If you will allow me to use the comparison, it is like, the trifling superficial inflammation which accompanies malignant pustule, as compared with the severe inflammation which accompanies a common boil. Simple laryngitis makes a great fracas, but diphtheritic in- 494 STRIDULOUS LARYNGITIS. flammation insidiously instals itself: the irritation which the latter causes in the parts which it invades, at first produces scarcely any fits of coughing, as I have just been remarking. To these slight symptoms a cough soon succeeds, which by its hoarseness and frequency recalls to one's recollection those which I have just been pointing out under the name of angina strid- ulosa: at a later period, a pseudo-membranous exudation is found to have covered the vocal cords, the mucous membrane loses its sensibility, pro- tected as it is by a sort of coat of mail from the action of air and mucus, by which otherwise its irritability might be excited. So much is this the case-and observers have been struck by the phenomenon-that in con- firmed croup [croup confirme] there is little cough, and sometimes none at all; the cough is at least as often silenced as the voice. This difference between the cough of stridulous laryngitis and of pseudo- membranous laryngitis is chiefly dependent upon entirely mechanical causes. If there be any notable structural alteration in the vocal cords, or if they be covered with a substance which cannot vibrate, there will be no vibration of the air as it passes over them. This can be shown by a very simple experiment. The larynx may be regarded as a wind instrument of the nature of a flute, or as an instrument having a tubal mouthpiece with expanded lips. Now, if we place a piece of moist parchment upon the lips of the mouthpiece, or on the openings in the flute, it will be impossible to obtain any vibration of air by blowing. When the cough remains hoarse and loud-croupy as it is called-in false croup, it is because the vocal cords are only swollen; and when it is muffled or extinct in true croup, it is because the larynx is covered with false membrane, producing an influ- ence on the vocal cords similar to that produced on the metallic lips of the clarionet and bassoon. Finally then-and that is the point I have been making for-croupy cough is not an indication of croup. Still, we can understand how the com- mencement of pseudo-membranous laryngitis may be invested with all the characters of false croup, and we can likewise perceive how it is, that when false membrane which covered the larynx has been expelled, the croupy cough should again be heard. Under such circumstances, however, it is soon again enfeebled, and finally, there is no sound : whilst this change is progressing, the severity of the suffocative symptoms increases. In stridu- lous laryngitis, on the contrary, as the cough loses its croupy character the difficulty of breathing diminishes. Cases are recorded in which stridulous laryngitis was accompanied by a feeble cough resembling thd cough of true croup; but these very exceptional cases do not diminish the value of the differential diagnostic characters to which I now call your attention. The remarks I have made on' croupy cough are also applicable to changes in the voice. In croup, the voice is first of all very much altered in tone: it then becomes very much weaker, not only during the paroxysms, but also in the intervals between them. In false croup, if it become feebler during the paroxysms, the feebleness is never to such a degree as in true croup; and during the intervals it regains its strength to a certain extent, though remaining hoarse and broken. When stridulous laryngitis is coincident with common membranous sore throat, formed by thick confluent patches of membranous deposit, however well-marked the laryngeal symptoms may be, hesitation is allowable: it is only by the subsequent progress of the case, that you can clearly establish your diagnosis. You must know, therefore, to wait before forming your opinion; but whilst you are waiting, treat the pharyngeal affection exactly as if it were diphtheritic. (EDEMA OF THE LARYNX. 495 An experienced practitioner will not mistake stridulous laryngitis for spasm of the glottis or thymic asthma; but as some authors have fallen into confusion on the subject, I shall rapidly point out the signs by which the differential diagnosis of the two affections may be established. We have just seen that in stridulous laryngitis there are suffocative seizures, that the cough and voice are croupy, and that during the whole course of the malady, even in the intervals between the paroxysms, the patients retain a certain amount of hoarseness in the cry, in the voice, and in the cough. In spasm of the glottis, there is first of all this difference, that the paroxysms are equally liable to occur during the day and the night: then, again, when there are suffocative seizures, they are not accompanied by even slight hoarseness of cry, voice, or cough. Let me add, that the paroxysms do not generally recur two, three, or four times in the space of a few minutes, as is the case in false croup. However many attacks there may be in the twenty-four hours, there is always a long interval between them; and as soon as they are over, the patients breathe easily, retaining apparently no recollection of what they have suffered. The treatment of false croup need not detain us long; for, as I have already told you, the disease cures itself. I shall only recall to your recol- lection the treatment adopted by Graves, of which I have already spoken in my clinical lectures on measles, and which consists in passing along the skin, under the child's chin and in front of his neck, a sponge soaked in very hot water. This operation is repeated several times at intervals of ten or fifteen minutes: it causes a sort of determination to the skin, under the influence of which the oppression usually ceases in a remarkable manner, while the cough loses its hoarseness. This powerfully efficacious treatment has the advantage of being marvellously simple; and it is usually sufficient without any other means, such as emetics, being employed in connection with it. But even when there is no false membrane in the larynx, the swelling of the mucous membrane may be so great as to place life in immediate jeopardy, and to impose the necessity of performing tracheotomy. In such a case as this, my excellent friend Dr. Adolphe Richard restored to its mother, a poor child dying from suffocation, the consequence of stridulous laryngitis. LECTURE XXVI. CEDEMA OF THE LARYNX. (Edema of the Larynx is not in itself a Disease: it is a Complication of Dis- eases of the Larynx.-Improperly named (Edema of the Glottis.-Some- times, but not often, Independent of Inflammation.-Predisposing Causes. -Exciting Causes.-Frequently supervenes in Chronic Laryngitis.- Common Termination of what is called Laryngeal Phthisis.- Treatment: TopicalMedicationis Important.- Often necessary to resort to Tracheotomy. Gentlemen: Some of you, no doubt, recollect a young woman of twenty- one,.who was brought to the Hotel-Dieu, on the 24th June, where she occu- pied bed No. 20 of our St. Bernard's Ward. She left the hospital perfectly cured, on the 2d July, after having had all the symptoms of oedema of the 496 (EDEMA OF THE LARYNX. larynx. She was, on a former occasion, for a month in our wards under treatment for puerperal peritonitis. She had been six weeks out of hos- pital, when she was seized with violent sore throat, difficulty of deglutition, and a good deal of swelling of the tonsils. When I first saw the patient, the affection had existed ten days, and had already made rapid progress. It soon produced an amount of difficulty of breathing, which gradually increased till it became so serious as to bring on suffocative paroxysms. During inspiration, the dyspnoea was accompanied by laryngo-tracheal whistling, but the expiratory sound remained normal, and the voice retained its natural tone. I found the patient with a good deal of oppression: the countenance was pale, and presented that peculiar expression observed in persons threatened with asphyxia. The pulse was small and miserable; the submaxillary region was swollen and painful. On examining the throat, I saw that the mucous membrane of the pharynx had a bright red color: on carrying the finger towards the laryngeal orifice, I found that there was oedematous swelling of the epiglottis and aryteno-epiglottidean ligaments. I had no hesitation as to the diagnosis: it was a case of what has been called oedema of the glottis. I ordered an injection, as soon as possible, into the back part of the throat, of water-spray strongly charged with tannin. Similar injections were made every hour by means of the spray apparatus which you know, and which has been modified by Mathieu. Under the influence of this medication, the severity of the symptoms moderated. At my second visit, on the fol- lowing day, a great improvement was evident. During the whole day, there had been only one suffocative seizure, and it was of a much less violent character than those of the previous evening. The breathing had become free, and was not accompanied by any abnormal sound. There was also a great diminution in the swelling of the epiglottis and aryteno-epiglottidean ligaments. Notwithstanding the amendment, I ordered the treatment to be continued. For three days, she had one suffocative seizure in the twenty- four hours; but during the intervals between the attacks, respiration was natural. Although, at this date, the cure may be considered to have been complete, and the general condition very satisfactory, the patient did not leave the hospital till four days later, up to which time convalescence had been thoroughly maintained. To-day, a new case of oedema of the larynx has been presented to our notice. The patient, a woman of fifty-two years of age, occupies bed No. 25 of the same ward. In her, oedema of the glottis is a sequel of chronic laryngitis. The recurrence of the seizures, their severity, and the immi- nence of the danger, necessitated surgical interference; and tracheotomy, the only means of preventing death, was resorted to with complete success. You have also recently had an opportunity of interrogating a patient who occupied bed No. 23 of St. Agnes's Ward. This man, aged fifty- eight, who came into hospital on account of a deepseated swelling of the lateral region of the neck, had on the anterior part of that region, two cen- timetres above the sternal fourchette, a linear cicatrix, the origin of which is thus accounted for. In 1858, he was under treatment, in the wards of my lamented colleague, Dr. Legroux, for chronic laryngitis of syphilitic character. During fifteen days, he had been subjected to specific treat- ment, when suddenly, during the night, after a chill, he experienced great difficulty of breathing: next morning, the existence of oedema of the larynx was ascertained ; as asphyxia was imminent, tracheotomy was at once per- formed. The danger was averted; and in three days after the operation, it was found practicable to remove the canula. The patient was soon in a (EDEMA OF THE LARYNX. 497 condition to resume the specific treatment, by which, in a few weeks, he was cured of the syphilitic laryngitis. Gentlemen, I must not omit to speak to you of a formidable affection which you have had several opportunities of seeing in my wards during the last few years. When lecturing upon dothinenteria, I have already called your attention to cedema of the glottis, in connection with two patients who suffered from it, and in whom you had the opportunity to see the gradual development of the symptoms. In two other cases, I showed you, on the dead body, the larynx of persons who had sunk under tubercular phthisis, and in one of whom tracheotomy had been rendered imperative from oedema of the glottis, as in the case of the woman occupying bed No. 25 of St. Ber- nard's Ward. Finally, when speaking to you of scarlatina, I mentioned oedema of the glottis as one of the complications liable to supervene in the decline of that pyrexia. By oedema of the glottis is meant a serous, purulent, or sero-purulent infiltration of the submucous cellular tissue of the epiglottis, and aryteno- epiglottidean folds, generally extending to the interior of the larynx. So accurate is this description of the affection called cedema of the glottis," that every author who has written on the subject states that the diagnosis has to be made by an exploration of the parts by the finger. Now, how- ever deep you may pass the finger into the back part of the throat, you cannot by any possibility get the finger to reach beyond the epiglottis and the aryteno-epiglottidean ligaments. (Edema of the glottis is, therefore, an incorrect name to apply to this affection, because in the majority of cases, its seat is not the glottis but the margin of its superior orifice. Again, the swelling of the aryteno-epiglottidean folds is itself a cause of symptoms which are otherwise very much more serious than those to which it gives rise when it only occupies the vocal cords. If you reflect upon the ana- tomical arrangement of the aryteno-epiglottidean folds, you will under- stand that, when they swell in so remarkable a manner as to form large cushions, trembling at each inspiration, as the air enters the larynx, they become glued to one another, closing by a sort of valve the upper part of the air-passage, while the vocal cords, being formed of a more compact tissue, and therefore not easily infiltrated, do not swell out in the same proportion. Those who have witnessed Czermak's experiments with the laryngoscope have had an opportunity of convincing themselves, that during forced inspiration, the vocal cords diverge in such a manner as to form a very large opening.* Although the name " oedema of the glottis " [oedhne de la glotte] was, and still is, in constant use, '"laryngeal cedematous sore throat" [angine laryngee oedemateuse] is preferable. Besides possessing the advantage of not falsely describing the seat of the affection, the name last mentioned expresses the peculiar character, without in any way asserting its pathological nature, an objection which applies to the term " submucous laryngitis " [laryngite sous-muqueuse'], which has also been given to it, and which conveys the idea of an inflammatory malady. (Edema of the aryteno-epiglottidean folds is nearly always the result of inflammation, but it cannot be denied that, in some rare cases, inflammation has either had no part or only a very secon- dary part in causing the oedema. Some of you may recollect my stating, on a former occasion, that scarlati- nous anasarca may invade deepseated parts, causing effusions in the serous cavities-pleurisy and pericarditis-also, cedematous infiltration of the veil of the palate, uvula, and aryteno-epiglottidean folds. In the lecture to * Czermak: Du Laryngoscope. 8vo., Paris : 1860. vol. i.-32 498 (EDEMA OF THE LARYNX. which I refer/ I related the history of a child seen by me in consultation with my colleague, Dr. Henry. This patient having been suddenly seized, during the course of an attack of scarlatina, with considerable anasarca, would have been lost from oedema of the aryteno-epiglottidean folds, had it not yielded to cauterizations with the nitrate of silver, and insufflations of alum into the back of the throat. I also laid before you the history of another case communicated to me by my colleague, M. Bichet. The patient, a child, was similarly affected, and was rescued from impending death by tracheotomy. To these cases may be added others published by Baudelocque and Barrier.f These examples are more than sufficient to prove that there exists a non- inflammatory form of oedema of the glottis. In these cases the infiltration takes place into the cellular tissue of the aryteno-epiglottidean ligaments, from causes similar to those which produce effusions in other parts of the body, without there having been preceding inflammation. I am aware that as an objection to illustrations derived from scarlatinous patients it may be said that in scarlatina there is always a pharyngeal in- flammation, and that this inflammation being the cause of the oedematous congestion of the aryteno-epiglottidean ligaments, the oedema is consequently inflammatory in its nature: but to argue thus would be to exaggerate the bearing of the facts. Might it not be said, with equal justice, that the in- filtration of the subcutaneous cellular tissue is produced under the influence of the inflammation of which the skin has been the seat during the eruptive period ? Scarlatinous anasarca, however, does not occur during the erup- tive period, but in the decline of the fever: moreover, it is by no means those who have had the eruption in the most violent manner who are most frequently the subjects of anasarca ; and, again, the anasarca supervenes in patients who have not had the exanthematous eruption at all. In respect of oedema of the glottis, it is possible that the sore throat by which it has been preceded favors its production, but if so, the pharyngeal inflammation is only the immediately exciting cause, the predisposing being here the principal cause. It is reasonable to believe (although I cannot adduce examples in sup- port of the view), that this non-inflammatory oedema of the larynx may take place in connection with every disease during the course of which we see anasarca supervene-in albuminuria for instance; but, apart from these cases, idiopathic oedema of the glottis is far from occurring so frequently as some authors have alleged: and I repeat, that you will almost constantly see oedema of the larynx depending on inflammation, a fact which Bayle established, and was the first to describe. (Edema of the larynx may be either primary or consecutive : it is primary when it is the result of an inflammatory action advancing towards the larynx or pharynx, and simultaneously to the aryteno-epiglottidean ligaments; and it is consecutive when it depends upon an organic alteration of the larynx. In the first case the inflammation is propagated to the seat of lesion, the aryteno-epiglottidean ligaments: in the second case the serous infiltration is due to engorgement of the vessels connected with the diseased parts : but in neither can the oedema of the larynx, as it has for its starting-point an ulcerated and consequently an inflamed tissue, be regarded as independent of inflammation. What then are the different circumstances in which this oedema super- * See p. 153 of this volume. j- Baudelocque : Gazette des Hopitaux, 1834. Barrier: Traite Pratique des Maladies de 1'Enfance, t. ler, p. 456. (EDEMA OF THE LARYNX. 499 venes ? Before answering this question, let me say a word upon the con- ditions which favor the production of oedema of the larynx. These conditions exist in the texture itself of the affected parts. You know, gentlemen, that an inflammation of the skin, a common boil for ex- ample, causes swelling of the surrounding parts, which, within certain limits, retains the mark of the finger when pressure has been made upon them with it. (Edematous swelling, resulting from an afflux and effusion of fluids into the cellular tissue, will proportionately have the more tendency to be produced, the less the degree in which the tissue is compact. We therefore see it in the most marked degree in the eyelids and prepuce, when there is an inflammatory afflux to these parts; the presence of variolous pustules, for example, upon the eyelids, will determine a great amount of swelling in these membranous curtains, and, in the same way, a variolous pustule on the prepuce may occasion swelling sufficient to impede the pas- sage of urine. Well then, the uvula, epiglottis, and aryteno-epiglottidean ligaments present identical conditions of structure, and as these organs are composed of a still looser cellular tissue, you can understand how it is that they have a tendency to become oedematous, not only under the influence of a direct attack of inflammation, but likewise from inflammation of neighboring parts causing a stasis and consequent effusion of fluids. Let us now review the different circumstances in which oedema of the larynx may supervene. One morning fifteen years ago, when the physicians of the Necker Hos- pital were arriving for their visit, my honorable colleague Bricheteau and I were together in the vestry, when we were summoned in haste to a person just brought in, who was dying in frightful paroxysms of suffocation. He was a vigorous man of thirty-five or forty years of age, who had been picked up on the Boulevard des Invalides. Horrible anxiety was depicted in his countenance: his respiration was embarrassed to the very last degree; and during inspiration, he emitted a whistling sound from the larynx, while expiration was a little less difficult than inspiration. I at once introduced my finger deep down into the throat, and detected great tumefaction of the epiglottis and aryteno-epiglottidean ligaments. Interrogating the patient, who-though speaking with great difficulty, gave a good account of his state-we learned that on the previous evening, having drunk too freely at a wine shop, he had been turned out into the street, where he fell asleep. The night was cold ; and towards morning, he awoke with a violent sore throat, which was almost immediately accompanied by great difficulty in breathing: in an hour or two, it had attained the point at which we saw it. The pharynx was of a bright red color, and the veil of the palate was much swollen : the enlarged uvula, more than three centimetres in length, trailing on the tongue, was infiltrated with serosity, and looked like a large yellow grape. This oedematous condition of the uvula led us to conclude that the epiglottis and aryteno-epiglottidean ligaments were in a somewhat similar state, and in fact showed us the nature of the case. We saw that we had to do with oedema of the larynx. Under the influence of a chill, the man had contracted a catarrhal sore throat, a violent inflammation, which invading the whole of the throat, and extending to the entrance of the larynx, had attacked the epiglottis and aryteno-epiglottidean ligaments, in the same manner in which it had laid hold of the uvula and veil of the palate. Tracheotomy was performed : and in a few days the patient was cured. In the young woman of bed No. 20, St. Bernard's Ward, of whom I spoke at the beginning of this lecture, the laryngeal affection, which presented characters almost more alarming than those seen in the patient 500 (EDEMA OF THE LARYNX. of the Necker Hospital, was also dependent on a catarrhal inflammation of the pharynx. Thus, gentlemen, you see that catarrhal pharyngitis may be one of the causes of oedema of the larynx. With that cause may be grouped erysipelas of the pharynx; whether the erysipelas be originally developed in that region, or in the face, it will extend to the pharynx. You will find two cases illustrating this point in the thesis of Dr. Laillier, to whom they were communicated by Dr. Gubler.* Speaking in more general terms, I may say, that any inflammatory affection of the pharynx or back part of the mouth, irrespective of its par- ticular nature and seat, may originate the affection now undei' considera- tion. A simple inflammatory sore throat, inflammation at the root of the tongue, or inflammation excited by the presence of a cancerous tumor of that organ, will sometimes lead to oedema of the glottis, when the inflam- matory afflux extends to the epiglottis and aryteno-epiglottidean ligaments. The circumstances, however, in which oedema of the larynx is the conse- quence of inflammation descending from the parts above, or directly attack- ing the aryteno-epiglottidean ligaments, are much less common than those in which it is the direct result of acute or chronic inflammation of the larynx itself. We can understand the facility with which the fluxionary movement which accompanies acute inflammation of the larynx may extend to the ligaments of the epiglottis, and even to the epiglottis, and determine in the cellular tissue which enters into their composition, a more or less consider- able accumulation of serosity. This is chiefly observed in laryngismus stridulus, a form of laryngitis which is rare in adults and frequent in chil- dren. In that disease, it is not uncommon to see oedema of the mucous membranes not only originate in the larynx itself, but extend likewise to the aryteno-epiglottidean ligaments: the paroxysms of false croup also present the characteristic symptom of oedema of the larynx,-whistling in- spiration, and inspiration more labored than expiration. In describing to you the history of small-pox, I noticed the laryngeal complications met with in the eruptive stage of that disease: I mentioned three patients who were carried off by frightful suffocative paroxysms, and I stated that at the autopsy of one of them, appearances of inflammation were found in the larynx, and variolous pustules below the glottis. I am not aware of any cases having been recorded of oedema of the glottis de- pendent on small-pox; but looking to the cases to which I have now referred, one can quite well conceive that the affection may supervene in the course of small-pox, in consequence of pustules being developed upon, and in the neighborhood of the aryteno-epiglottidean ligaments. But the most frequent causes of oedema of the larynx, are the more deeply- seated affections of that organ. I refer to laryngeal ulceration, acute or chronic, embracing several species, which have been long known under the generic term laryngeal phthisis-to non-specific laryngeal ulceration-and to syphilitic, cancerous, and tubercular ulceration of the larynx. Exclusive of the cases in which non-specific or what may be called idio- pathic ulceration of the larynx supervenes after severe fevers (as in the two patients of whose cases I spoke when lecturing on dothinenteria), this species is rare. Generally, ulceration of the larynx is of one of the other species now enumerated, of which the tubercular is the most common, and to which alone the name-the objectionable name-of laryngeal phthisis is at all applicable. Were this term to be rigorously and literally interpreted, * Laillier: Sur I'CEdeme de la Glotte. [Thfcse] : Paris, 1848. (EDEMA OF THE LARYNX. 501 we should say that it signified a chronic disease of the larynx capable in itself of giving rise to consumption. But it results from the anatomy of the parts, that patients sink most frequently under the cedematous affection before the disease has reached the last stage of marasmus. Nevertheless, there are cases-very exceptional cases-in which death may .be the consequence of consumption. At first it seems difficult to under- stand how an inflammation of the larynx can of itself lead to consumption. We can conceive chronic inflammation, ulceration, or suppuration of the kidneys, intestines, bladder, or large extent of cellular tissue, having the power of contaminating, day by day, the mass of the blood, exciting fever, and causing the patient to waste away; but we cannot so readily conceive such consequences being the result of similar conditions of the larynx, the morbid surfaces of which are so small in extent, the products of their sup- puration so moderate in quantity, and their sympathetic relations so unim- portant. But there is another point which here requires to be taken into consideration. The ulcerations burrow deeply, and extend into the larynx: the epiglottis and the aryteno-epiglottidean ligaments participate in the inflammation : for a long time these parts are turgid, but not to a degree suf- ficient to cause complete obstruction to the passage of air: they have acquired excessive irritability: the larynx, of which the muscles and nerves have become pathologically modified, can no longer act in a normal manner. The patient breathes with difficulty: he is prevented from having a minute's sleep, and coughs incessantly from the irritating action of the air on the affected parts: cough is likewise brought on in fits, by the contact of alimen- tary substances and drinks, which, from difficulty of deglutition, are con- stantly getting entangled in the air-passages, and so exciting fears of suffo- cation. Under these conditions, the wretched sufferer refuses to take food, except when forced to do so by the imperious demands of hunger. His nutriment, therefore, is insufficient, and he falls into a state of emaciation which leads him to his grave. Laryngeal phthisis, I repeat, is quite an exceptional termination of laryngeal ulceration. The most frequent cause of death is oedema of the larynx, resulting from previous disease of the larynx. Whether the inflammation of the larynx be simple or syphilitic, tuber- cular or cancerous, oedema may supervene, when there are more or less extensive and more or less numerous ulcerations. Thus it happens, gentlemen, that we frequently meet with individuals,, who, having to a certain extent lost their voice from syphilitic disease, con- tinue to speak with more and more difficulty, and increasingly to, suffer from difficult breathing. The dyspnoea, which at first existed only when they exerted themselves in some unusual manner, such as walking more quickly than usual, or ascending a stair, at last becomes permanent, being present even when they remain in complete repose. Inspiration, which is more embarrassed than expiration, is accompanied by a characteristic laryngeal whistling ; and the symptoms go on increasing in severity from day to day, till real suffocative attacks supervene. By introducing the finger behind the tongue, the condition of the epiglottis and aryteno-epi- glottidean ligaments can be ascertained : by this proceeding it will be found, that they are swollen, and in a state of cedematous puffiness. This oedema of the glottis is dependent upon an inflammation of the larynx,, characterized by primary or secondary syphilitic ulcerations, whether the disease has begun in the larynx or pharynx. The same phenomena are observed in persons affected with tubercular laryngitis, of which the most common lesions are erosions, involving only the mucous chorion, or ulcerations, presenting great variety in. number,, 502 (EDEMA OF THE LARYNX. form, extent, and depth. The number of the ulcerations is generally in an inverse ratio to their size, although it is by no means unusual to find a single very small ulcer on the margin of the vocal cords, or at the bottom of one of the ventricles. Ulcers may invade the entire larynx, vocal cords, aryteno-epiglottidean ligaments, and mucous membrane of the epiglottis: of the latter, Dr. Belloc and I, in our treatise on laryngeal phthisis, have given an account of a remarkable example, and illustrated it by a draw- ing. With regard to form, the ulcerations are sometimes rounded and are sometimes irregularly circumscribed : their edges are at times jagged, and at other times flattened : their depth also is variable. In the majority of cases, the ulceration evidently begins in the mucous membrane, but in others, we meet with submucous abscess, when it is dear that the ulcera- tion is produced in the same way in which some cutaneous fistulae are formed. Under the influence of an unobserved cause, or in consequence of irritation excited by exposure to cold, a more acute inflammation super- venes around the ulcerations ; the fluxionary movement is propagated to the aryteno-epiglottidean ligaments, and serous infiltration into their cel- lular tissue takes place, the symptoms of oedema of the larynx being thereby produced. When the laryngitis-whatever may have been its cause-has led to necrosis or caries of the cartilages, oedema of the glottis is inevitable : under such circumstances, it is, so to speak, a necessity. These structural changes of the cartilages of the larynx occur in simple ulcerous laryngitis, as, for example, in those which follow aggravated fevers. In relation to this point, I ask you to recall to your recollection cases which we observed together, and on which I dwelt too long, when reviewing the sequel® of dothinenteria, for it to be necessary now to repeat what I then said. These changes are met with in syphilitic ulcer- ous laryngitis. They are most common, however, in tubercular ulcerous laryngitis. The ulcerative process, burrowing deeply, reaches the cartilages, which it denudes ; then, according to the greater or less rapidity of the ulcerative inflammation, there is found, either necrosis without previous ulceration of the cartilages, or caries of the cartilages ; or, in other cases, there is ossifi- cation along with necrosis. Necrosis without ossification is observed in acute ulcerous laryngitis following aggravated fevers : caries, which I have never seen coincident with tubercular laryngitis, is almost invariably ob- served in very young subjects; while in persons of more advanced years, when the laryngitis has been of long standing, it is necrosis that we find, and it is always accompanied by ossification, the latter, in fact, has even preceded the necrosis, the ulceration which is the cause of the necrosis hav- ing commenced by determining inflammation of the perichondrium, and a subsequent exudation of osseous matter into the subjacent cartilage : then, ulceration reaching the ossified cartilage, it becomes the more readily ne- crosed, that ossification has deprived it of a great part of its vitality. In old people, in whom ossification of these cartilages has pretty generally taken place, simple chronic laryngitis, irrespective of any special diathesis, leads to the structural changes of the larynx of which I have been speak- ing ; consecutively also to oedema of the glottis, as occurred in the patient occupying bed No. 25, St. Bernard's Ward. Gentlemen, you can understand that when once necrosis of the cartilages has begun, oedema of the larynx inevitably follows. Here, as in necrosis of the bones, where the sequestra must be extruded, as also in all tissues, in the cellular tissue, for instance, where the dead portions must be sepa- (EDEMA OF THE LARYNX. 503 rated from the living-the rapidity with which the separation and elimina- tion take place is proportionate to the vitality of the tissues. In respect of bones, what takes place? The irritation caused by the sequestrum induces suppurative inflammation; and if the necrosis be sub- cutaneous, the pus, sooner or later, makes its way to the surface. Some- times, the opening becomes cicatrized, but if this occur, it soon reopens, unless other openings form in the neighborhood to afford an exit to the pus which is being constantly secreted : finally, a fistula is formed, which con- tinues to exist till the whole of the dead portions of bone have been elimi- nated. The inflammation extends to the soft parts, which swell, and be- come the seat of oedematous engorgement. In necrosis of the cartilages of the larynx, the course of events is simi- lar. As soon as there is necrosis, whether of the cricoid cartilage, which is most common, or of the thyroid cartilage, which is less usual, an abso- lute necessity exists that the necrosed part be eliminated. During the whole of the period of elimination, suppuration is going on : abscesses form under the laryngeal mucous membrane, which they detach, and from the inflammatory afflux extending at the same time to the neighboring cellular tissue, that becomes the seat of more or less pasty induration. To pursue still further our comparative study of the manner in which bone and cartilage is affected, let us suppose an individual with necrosis of the tibia suddenly taking erysipelas of the leg, under the influence of one of those epidemics so common in our hospitals. This attack will have as its starting-point the existing fistula; and the erysipelas, acquiring great intensity, will occasion an engorgement extending to a greater or less dis- tance around the primarily affected parts. Suppose, again, that an individual suffering from ulcerous laryngitis and necrosis of the cartilages, take acute inflammation of the larynx, from exposure to cold, undue exertion of the voice, or other cause, that inflamma- tion, being greatly aggravated by that already existing, will extend to dis- tant parts, will reach not only the vocal cords, but likewise the aryteno- epiglottidean ligaments; and the patient will have all the symptoms of oedema of the larynx. I ought also to notice a frequent cause of oedema of the glottis in very young children in England, North America, and Russia, where tea is an ordinary beverage. In every family there is almost constantly a kettle on the fire: and the children going to drink from the beak of the kettle or tea-pot when the boiling water is about to be poured out, terrible burns of the mouth and throat are the result. No doubt the child immediately re- jects the water which he has taken into his mouth; but it has had time to come in contact with the epiglottis, the aryteno-epiglottidean ligaments, the veil of the palate, and the interior of the mouth. In general, for some hours after the occurrence of accidents of this description, they do not seem to be at all serious; but ere long, respiration becomes distressed, and all the phenomena of oedema of the glottis make their appearance. Mr. Jameson, surgeon to one of the Dublin Hospitals, has published a very interesting paper on this subject. He shows the necessity of resorting to tracheotomy as soon as the suffocative attacks occur; and he details several cases in which a cure was obtained by that proceeding. The canula ought to be removed as soon as the local effects of the burn have disappeared.* You know, gentlemen, the symptoms of oedema of the glottis. In a few rare cases, the disease declares itself suddenly, as occurred in my patient * Jameson : Dublin Quarterly Journal for February, 1848. 504 (EDEMA OF THE LARYNX. of the Necker Hospital. More frequently, according as it is dependent on an acute or chronic inflammation, the phenomena by which it is character- ized have been preceded by the symptoms which belong to these diseases, that is to say, by the symptoms of pharyngitis, tonsillitis, acute laryngitis, or chronic laryngitis. In the latter, the most frequent case, changes in the voice will have ex- isted for some time: the individual will have had for some time roughness of voice, which will at last pass into aphonia: his hoarse, dry cough will become less and less heard, till it ultimately becomes inaudible. At this stage, the disease of the larynx having made progress, respiration will have become more painfid. At first, the oppression is greatest during inspiration, which is accomplished with great effort, and is accompanied by a guttural snoring noise, which is sometimes very loud : at first, this noise is only heard during sleep. Expiration, hitherto easy, now, in its turn, becomes difficult. The malady advances, and the dyspnoea increases. The dyspnoea, which in the beginning of the attack was most severe at night, is now great both by day and by night; but during the night it is so urgent, that the patients are obliged at last to retain constantly the sitting posture. Orthopnoea be- comes incessant; and it has exacerbations which are suffocative seizures, and constitute the symptom characteristic of oedematous sore throat. These suffocative seizures have a very frightful aspect. The patient- with livid face, open mouth, distended nostrils, moist and protruding eye, the skin streaming with sweat-rises abruptly, and walks about the room, from time to time holding the articles of furniture, the jams of the mantel- piece, or the ratteens of the casements, seeking everywhere something to rest on that he may breathe more easily : sometimes, he will hold his head low and look down ; but more frequently, he will, with stretched neck, turn his head backwards: at last, he will sit down exhausted, but he will soon rise again and repeat the same postures. You see him in extreme excite- ment, throwing off' the garments which cover his head, neck, and chest, opening the windows in a sort of frenzy, that he may inhale the fresh air from without, and grasping his neck, as if for the purpose of wrenching from it some foreign body by which he was being strangled. Persons sometimes die in the first paroxysm of oedematous sore throat; but in general, the symptoms abate, and the suffocative attack ceases: the breathing, however, continues embarrassed, particularly during inspiration: the voice is scarcely audiblethe state of excitement is succeeded by col- lapse. When we proceed to examine into the state of the affected parts, we find that our means of investigation are unfortunately very insufficient. If in certain cases, inspection of the back part of the throat is of some use; if the existence of a catarrhal or inflammatory sore throat lead us to believe that the oedema of the glottis is dependent upon pharyngitis, this inspection too often fails to aid our diagnosis when the sore throat which preceded the laryngeal affection has entirely disappeared, or when the affection of the aryteno-epiglottidean folds is dependent upon disease of the larynx. In the latter case-which is the most usual-auscultation does not afford information as to the state of the parts nearly so good as that obtained by observing the manner in which respiration is performed, and attentively studying the modifications of the voice. It is only the touch which can give us some positive indications; but to whatever degree of perfection this mode of exploration is carried, it does not do more than enable us to recognize the oedematous swelling of the epiglottis and aryteno-epiglottidean ligaments. Exploration by the finger must be practiced in a very careful manner. You recollect that whilst I was examining the throat of a woman (EDEMA OF THE LARYNX. 505 with my finger in the most guarded possible way, I induced a suffocative seizure which very nearly proved fatal. To ascertain the existence of lesions is unquestionably of great importance in the diagnosis of oedema of the larynx, but it throws no light upon the nature of the affection whence the oedema arises. Examination of the larynx by a suitable speculum was felt to be a likely means of attaining this end. Long prior to 1837, when Dr. Belloc and I published our treatise on laryngeal phthisis, this idea had engaged the attention of practitioners ; and at the date of our publication we were occupied with the construction of a speculum, laryngis. At that time likewise M. Selligue, an ingenious mechanician, who was also a sufferer from laryngeal phthisis, made for his physician, an apparatus consisting of two tubes, one for throwing light on the glottis, and the other for affording a view of the image of the glottis, as reflected in a mirror placed at the guttural extremity of the instrument. There were, however, serious defects in this instrument; and the difficulties in applying it were so great, that I long since ceased to use it. Laryngoscopy has been carefully studied in England and Germany; and you can read in the Archives Generales de Medecine for February, 1860, an account by my friend Dr. Lasegue of the results arrived at by our colleagues on the other side of the Channel and beyond the Rhine. When laryngoscopy shall have attained a greater degree of perfection, it will no doubt render service not only in the diag- nosis but also in the treatment of laryngeal affections-particularly in the treatment of oedema of the glottis, for sight ought certainly to assist the hand in the application of the topical remedies which are of such essential importance in treating that affection.* I must not, however, exaggerate the practical utility of the laryngoscope in the class of cases we are now considering. The application of instruments is not well borne by the larynx, particularly when there is a liability to suffocative seizures; and you have observed that M. Czermak, notwithstanding the great experience which he had in the use of the laryngoscope, was only able to get a good view of the larynx in patients with very tolerant throats, and in whom respiration was not much embarrassed. When there is suffocation, the introduction of the laryngoscope increases the anxiety, and it is only by stealth, if I may use such an expression, that one can get a view of the vocal cords and upper part of the larynx. I now propose to consider the symptoms and progress of oedema of the larynx. I stated, gentlemen, that patients are occasionally carried off in the first suffocative seizure; but that usually this attack passes off, leaving, how- ever, embarrassed breathing. I also stated, that there is a variety in the early symptoms, according to the oedema of the larynx being depen- dent upon acute or chronic inflammation. In the former case, the attack comes on abruptly, and the symptoms are of a violent, irregular character, recurring several times within the twenty-four hours ; in the second case, the seizures supervene at distant intervals, at intervals of from eight to fifteen days, or longer; but after a time, the duration of the intervals diminishes, so that in the course of the twenty-four hours, there are several attacks, those which occur during the night being the most violent. When oedema of the larynx is a primary affection, or is connected with acute inflammation of the pharynx or larynx, its progress is more rapid, and the chances of a favorable termination are also greater, which arises from the affection being transient in its nature like the pathological state * See the work of Czermak : " Du Laryngoscope et de son emploi en Physiologie et en Medecine.'' Paris, 1860. 506 (EDEMA OF THE LARYNX. on which it depends. Spontaneously, therefore, or under the influence of appropriate treatment, resolution of this inflammation takes place, the cure being certain and complete. I am not speaking to you, gentlemen, of very exceptional cases in which recovery is the result of another mechanism which you will find pointed out in some works,-the opening of an abscess formed in the substance of the aryteno-epiglottidean ligaments. When oedema of the larynx is connected with chronic inflammation of the larynx, or structural alteration of the cartilages, the progress of the symptoms is very different; and from what I have already said, you can understand that they then have a disposition to repeat themselves. There is in fact an inevitable necessity for the elimination of the necrosed parts : the eliminative process gives rise to suppuration, and to the formation of abscesses, which by raising up the mucous membrane, diminishes the calibre of the glottis, already narrowed by the thickening of the vocal cords caused by their inflammatory engorgement; and which engorgement, by extending to the aryteno-epiglottidean ligaments, causes them to become infiltrated. If the pus make an exit for itself into the interior of the larynx, or externally by the skin (examples of which I have seen), if the inflamma- tory action is at first very circumscribed, and quite passes away, the suffo- cative symptoms will decrease more or less completely, in proportion to the greater or less size of the opening in the abscess, the patient, however, retaining hoarseness of voice, some amount of aphonia, and difficulty of breathing, which latter depends on the vocal cords and laryngeal mucous membrane remaining in a thickened state. But this amendment is only temporary: the causes continue, and will, sooner or later, induce a repeti- tion of the consequences. The organic lesion advancing and the (edema- tous infiltration becoming permanent, the symptoms recur with increasing intensity; and unless art interpose, the patient will probably be carried off in a suffocative paroxysm. Death also frequently occurs in the intervals between the attacks. The patients becoming weaker and weaker, more and more prostrated by each attack, fall into a state of drowsy listlessness, and sometimes expire in perfect possession of consciousness. In such cases, tracheotomy often gives no fresh life, the victims sinking, in the same man- ner as certain asphyxiated persons sink, after the causes of asphyxia have been removed. Although the principal obstacle to respiration in oedema of the larynx is generally seated in the aryteno-epiglottidean folds, this inflammatory oedema may also become developed in the cellular tissue of the laryngeal mucous membrane itself: thus, in the cases in which there is none of that shrill whistling inspiration which particularly belongs to oedema of the aryteno-epiglottidean folds, it is probable that the chief obstacle exists in the situation of the vocal cords. Then the patient, who generally has seri- ous lesions of the cartilages of the larynx and particularly of the cricoid cartilage, has no whistling inspiration: there is puffiness of the mucous membrane and oedema of the submucous cellular tissue covering the affected cartilage: there is only very greatly embarrassed breathing, the inspired air traversing the larynx, and producing there a more or less harsh but not shrill sound, while the expiratory murmur is still percepti- ble : there exists in fact a variety of wheezing without any shrill whistling sound. You may have observed this state of matters in a patient occupy- ing bed No. 3 in St. Agnes's Ward. The man to whom I refer is sixty- three years of age: for a long period he had been the subject of chronic laryngitis. Examination by the laryngoscope enabled us to ascertain that there was no oedema of the aryteno-epiglottidean folds, while we saw diffuse (EDEMA OF THE LARYNX. 507 redness of the upper part of the larynx and vocal cords, and below them, a serious structural change. We were ignorant of the cause of the chronic laryngitis: no benefit had resulted from treatment, and the embarrassment in respiration was rapidly increasing. Suffocative seizures frequently occurred during the night, the extremities at the same time becoming cold. Fearing that the patient might die in one of these attacks, I requested M. Dumontpallier to perform tracheotomy. The operation is, as you know, difficult in old people. In them, the trachea is nearly always very deeply seated. The large veins must be avoided with care, lest hemorrhage com- plicate the proceedings. When the trachea has been properly isolated, the most difficult part of the operation remains to be encountered-the opening of the canal, which is generally ossified. The upper rings of the trachea ought to be included between the blades of the scissors, care being taken to avoid cutting the mucous membrane. Before penetrating the mucous membrane of the trachea, it is necessary to remove a portion of the rings, a precaution without which it is impossible to introduce the canula. In the aged, therefore, there is a particular time for opening the mucous mem- brane of the windpipe, and that time is the last stage of the operation. In our patient, tracheotomy was performed in accordance with these rules, and the canula was easily introduced. The patient at once breathed freely : and no untoward event occurred after the operation. I said to you at the time, that it would probably be right to leave the canula in the trachea, because, whether the affection was cured or not, such an amount of stricture would remain as to leave an insufficient passage for the entrance of the air required in hsematosis. Well then, the man, after remaining six months in our wards, was received as an incurable into the Bicetre. He could not remain more than a minute without the canula, and when it was being cleaned, it was necessary to keep the tracheal opening in a patent state by means of the dilator, for otherwise a risk of suffocation would be incurred. From time to time, small sequestra from the cricoid cartilage were eliminated. I now come to the subject of treatment. When the inflammation is simple and very acute-when, as in our patient of the Hospital Necker, it is connected with violent inflammation of the pharynx or larynx-when the febrile reaction is intense-antiphlo- gistic remedies are at once indicated. One or two large general bleedings, and the abstraction of blood from the cervical region by leeches or cupping, will give great relief and moderate the severity of the symptoms. Recourse will afterwards be had to cauterization with nitrate of silver, to insufflation of alum or tannin into the back part of the throat, and as far down as the aryt- eno-epiglottidean ligaments. When it is practicable, scarification of these ligaments has been recommended. I have not bad the courage to practice this operation ; but Mr. Gordon Buck, surgeon to the hospital of New York, has published numerous cases of recovery from oedema of the larynx in which repeated scarifications of the epiglottis and aryteno-epiglottidean ligaments were performed. The instrument employed, a sort of blunt- pointed bistoury with a short curved blade, is carried to the back of the throat, the index finger being used as a conductor. Mr. Gordon Buck has, however, exaggerated both the utility and the facility of this operation. In reading over the cases reported by this honorable practitioner, it may be asked, whether the majority of the patients would not have recovered under simpler treatment. The cases, gentlemen, were acute, non-symptomatic cases of oedema of the glottis, an affection which as you know corresponds in the adult to false croup in the child, and which gets well of itself, not- withstanding the very alarming aspect of the symptoms. 508 (EDEMA OF THE LARYNX. Topical treatment is exceedingly useful. You saw me employ it success- fully, and to the exclusion of other remedial means, in the case of the patient of bed No. 20, St. Bernard's Ward: in that case, there was laryngeal (edematous sore throat dependent on catarrhal inflammation, unattended by much general febrile disturbance of the system. Let me call your attention to the manner in which I applied the treatment. It consisted in injecting (by means of a spray-apparatus) water-spray strongly charged with tannin. This excellent method of application, which is easy in adults, is in my opinion even more serviceable in chronic affections of the larynx, than in oedema of the glottis. Whatever may be the nature of the disease, whatever may be the laryn- geal lesion which has induced the oedema of the glottis, the first thing to do is to apply topical treatment. Under its influence, the local affection of the aryteno-epiglottidean folds may become modified to such a degree as to cause a cessation of the symptoms, and gain time sufficient for the inflam- mation which originated the oedematous infiltration to pass through its stages, and come to an end. Recollect, gentlemen, that a definitive cure cannot take place, unless the pharyngeal or laryngeal inflammation upon which the oedematous laryngeal sore throat depends is of the kind which spon- taneously terminates in recovery-unless the inflammation be either simple in its nature, or dependent upon a diathesis the manifestations of which we can prevent. Let me explain this point. We are justified in hoping for a radical and final cure when oedema of the glottis supervenes in the course of a simple ulcerous or syphilitic laryngitis, because in these cases we possess the means of effectively combating the pathological condition of which the oedematous affection is the result: but we cannot entertain such hopes when the oedema- tous affection comes on in the course of a tuberculo-ulcerous, or a cancerous laryngitis, for then the disease of the larynx is developed under the influ- ence of a diathesis beyond the resources of art. Supposing that we are for- tunate enough to master the symptoms of oedema of the glottis, we must be prepared for then* return. These considerations are still more applicable to cases in which oedema- tous laryngeal sore throat depends upon serious lesions of the cartilages of the larynx. When lecturing on dothinenteria, I mentioned the case of a young woman who became affected with oedema of the glottis after an attack of typhoid fever, and was entirely relieved after getting rid of some small osseous sequestra. This is certainly the most fortunate termination which can be met with; but it occurs too seldom to be counted on. The process of eliminating the necrosed parts is accomplished too slowly-in the case to which I alluded, the laryngeal malady was of nine months' standing- to prevent fear of the patient being carried off by a suffocative attack. When the oedema of the larynx depends on formidable lesions of the laryn- geal cartilages, it is necessary to wait to see whether there be a recurrence of the symptoms. Here the employment of topical treatment is explicitly indicated, because it will, by gaining time, afford the slight chance which there is of the fortunate result occurring which I have just mentioned. Sooner or later, however, it will be necessary to resort to tracheotomy. In conclusion, I shall now repeat what I said on a previous occasion when speaking on this subject. When we have to deal with patients affected with oedematous laryngeal sore throat, after we have tried the therapeutic means at our disposal, insufflation of tannin and alum, cauterization with nitrate of silver, and (when practicable) scarification of the aryteno-epiglottidean folds, we must hold ourselves in readiness to perform tracheotomy. Earlier or later, recourse to the operation will be determined by the severity of the aphonia: cauterization of the larynx. 509 suffocative seizures, the rapidity with which they follow one another, and the urgency of the dyspnoea in the intervals between the paroxysms. Finally, increased debility of the patient demands earlier recourse to the * operation. LECTURE XXVII. APHONIA-CAUTERIZATION OF THE LARYNX. Different Causes of Aphonia.-From Lesion, or without Lesion of the Larynx. -Nervous Aphonia.- Good Effects resulting from Cauterization, and sometimes even from the mere Introduction of the Laryngoscope. Gentlemen : A long period has now elapsed since I called the attention of practitioners to a mode of treatment which I had found wonderfully suc- cessful in certain cases of chronic aphonia. During the present year you have had an opportunity of judging of its efficacy, having seen me apply it in the cases of several young women who remained in our wards for some days. By the term aphonia, we mean a more or less complete loss of voice, the power of speaking remaining. The patient has not lost the power of utter- ing articulate sounds, as in dumbness, with which aphonia must not be con- founded ; the sound of the voice is only greatly enfeebled. The causes of aphonia are numerous, and also various in character. Chronic aphonia is generally a symptom of disease of the larynx, and is most frequently dependent on ulcerous laryngitis, of which I incidentally spoke in my last lecture. You will often meet with it in persons who have formerly had venereal symptoms, and it almost always occurs in tubercular laryngitis. According to one of my good pupils, Dr. Krishaber, whose researches have rendered him a very competent authority on the subject, syphilitic leads less frequently than tubercular laryngitis to complete aphonia, and the explanation of this is to be found in the nature of the lesions. In syphilitic laryngitis the lesions generally occupy in order of invasion: 1st, the epiglottis ; 2d, the superior thyro-arytenoid ligaments (or superior vocal cords); 3d, the aryteno-epiglottidean ligaments (the seat of suffusion, oedema, and even of suppuration) ; 4th, the mucous membrane of the vestibule of the larynx; 5th, the mucous membrane of the trachea; and 6th (quite as an exceptional occurrence), the inferior thyro-arytenoid ligaments (or in- ferior vocal cords). You will immediately perceive, gentlemen, that this last peculiarity explains the rarity of complete aphonia in syphilitic laryn- gitis. Dr. Krishaber adds, that when the aphonia is complete, it is almost never dependent on a lesion of the vocal cords properly so called, but is generally the result of the swollen, puffy superior vocal cords covering, and preventing vibration of, the inferior vocal cords. With the aid of a strong light-sunlight or electric light-we can see the color of the mucous membrane, and from that determine whether the lesion be due to syphilis or tuberculosis: if the mucous membrane have a dusky shade, the affection is syphilitic. It is more difficult to recognize the specific character of the lesion by the form of the ulcerations, as in both lesions it is very similar. The syphilitic 510 aphonia: cauterization of the larynx. ulcerations are deeper, and more frequently attack the cartilages, while in phthisis, the fibro-cartilaginous tissue alone is implicated. (Edema of the larynx is more common in ulcerous laryngitis depending upon syphilis, than in laryngitis arising from the tubercular diathesis. Tubercular laryngitis invades in succession: 1st, the mucous membrane of the superior thyro-arytenoid ligaments; 2d, the epiglottis; 3d, the in- ferior vocal cords; 4th, the aryteno-epiglottidean ligaments; 5th, the ves- tibule ; 6th, and exceptionally, the mucous membrane of the trachea. Syphilitic laryngitis shows a tendency to the formation of polypiform vegetations, which are met with throughout the whole extent of the larynx and trachea. In tubercular laryngitis, on the contrary, there are no vege- tations, but a peculiar appearance resembling a polypus is produced by puckering of the edges of the ulcerated mucous membrane. Cases of purely nervous aphonia, it is important to remember, are some- times met with in both diatheses. I shall have forthwith to speak of this class of cases. Dr. Krishaber has stated, in an oral communication, that there is most destruction of parts in simple, that is to say, in non-diathetic ulceration of the larynx, as, for example, in that which originates in chronic laryngitis, or occurs as the sequel of a severe attack of fever. When speaking to you of oedema of the larynx, I stated that it is in simple chronic laryngitis, in the ulcerous laryngitis consecutive to dothinenteria, that, nearly always, necrosis of the cartilages, and subsequent symptoms of the most formidable character, occur. Lesion of the recurrent nerves, accidental deformity of the larynx, the compression of that organ by a cervical tumor, or abscess, or the existence in its interior of vegetations, fungous growths, and polypi, may occasion aphonia; but it is not unusual to meet with it when there is no serious anatomical lesion ; and in such cases, the affection is not less obstinate, last- ing as it sometimes does for years. The method of treatment of which I wish to speak to you to-day, and which is not applicable to, or at least is of very little service in aphonia dependent on a serious affection of the phonetic apparatus, is exceedingly useful when the aphonia is independent of serious material lesions, and still more beneficial in those cases in which no lesions at all can be observed. There are two species of aphonia, distinguishable from one another by the manner in which the symptoms are developed. The one comes on gradually: from time to time, the voice is observed to be muffled, soon after which, it becomes increasingly hoarse. The tone of the voice is very deep when the patient rises in the morning, and in the evening, it is much more shrill. At this stage, it is only by making great efforts that cleai* sounds can be produced ; subsequently, there are days, when, after too much speak- ing, no effort avails, and the larynx absolutely refuses to produce any sounds. At first, this species of aphonia, which is intermittent, comes on chiefly in the evening: it afterwards becomes complete and continuous. It affects both sexes; but men are most subject to it. It is chiefly met with in persons who have to cry aloud, to sing or speak in a high pitch in the open air or in a large expanse. Consequently, singers, advocates, clergymen, naval officers, and itinerant hucksters are frequently subject to serious alterations in the tone of the voice, and at last to aphonia. This species of aphonia is often coincident with chronic follicular inflammation of the pharynx: the probability is that the inflammation extends from the pharynx to the mucous membrane of the larynx. Though in such cases, the lesion may be superficial, it has not less the power to alter very much the tone of the voice; and as it generally is a symptom of the existence of the herpetic diathesis, aphonia: cauterization of the larynx. 511 it is particularly obstinate. Nevertheless, arsenical fumigations, followed, at a later stage, by cauterizations of the upper part of the larynx, are generally sufficient to bring about permanent recovery. An engineer on the Spanish railways consulted me regarding an affec- tion of this kind. He did not derive much benefit from the iodide of po- tassium ; but his condition rapidly ameliorated from the use of arsenical cigarettes, made according to a formula which you know, and which is as follows: Take of Arseniate of Potash, ... 1 gramme [15 grains]. " Distilled Water, . . 15 grammes [15 fl. drachms]. Evaporate this solution upon a sheet of white paper which does not con- tain any glue. Having dried the paper make it into twenty cigarettes. Every morning, the patient ought slowly to inhale into the bronchi from eight to ten whiffs of the smoke of one of these cigarettes. Along with that treatment, I applied, every second day, to the upper part of the larynx, a very small sponge, fixed to the end of a piece of bent whalebone, slightly soaked in a saturated solution of sulphate of copper. From time to time, I substitute tincture of iodine for the sulphate of copper. Eight days of this treatment produced a remarkable improvement in the state of the patient. By the end of the month, the voice was quite restored. I then directed the patient to have recourse to the cigarettes on eight con- tinuous days, once a month, with a view to prevent a relapse. There is another species of aphonia, which begins abruptly, and without having been preceded by any other laryngeal affection. It is caused by a great shock to the nervous system: it is liable to occur in very irritable subjects, and particularly in hysterical women, in consequence of some violent moral emotion, such as fear, anger, bad news, or great joy. All of you know the classical story of the woman who, from finding her husband in the very act of adultery, suddenly lost her voice. Classical authors have hitherto taught that nervous aphonia is solely de- pendent on lesion of the recurrent nerves. Dr. Krishaber remarks that they seem all to have forgotten that the superior laryngeal nerves only supply the crico-thyroid muscles-the chief phonetic muscles. These muscles render the vocal cords tense by causing the thyroid to swing upon the cricoid car- tilage. They impart to the inferior vocal cords the oscillatory movements observed, by the aid of the laryngoscope, when the voice is normal. Aphonia, therefore, may either be dependent on a lesion of the superior laryngeal nerve or of the inferior laryngeal nerve, or on a simultaneous lesion of both nerves. When the superior laryngeal nerve only is affected, the aphonia is never complete: the patient can generally articulate the deep tones, and his voice is hoarse, but he cannot utter the higher notes. This statement is both supported and explained by the experiments of Charles Bernard. In fact, the section of the superior laryngeal nerves causes the voice to become hoarse, but does not produce its complete extinction : the hoarseness de- pends on paralysis of the crico-thyroid muscles, and an inadequate tension of the vocal cords. In patients thus affected, laryngoscopic examination demonstrates this fact in the most unquestionable manner. Thus it is, that although we can see the vocal cords approach and separate in a normal manner, the emission of sound is accomplished with difficulty. One is struck with the absence of oscillation of the vocal cords, which is indis- pensable to the production of normal voice, and which is dependent on the action of the crico-thyroid muscles. When the inferior laryngeal nerve is affected the aphonia is complete ; 512 aphonia: cauterization of the larynx. and the experiments of Ch. Bernard have shown that this is the case whether the affection be with or without lesion. By the aid of the laryn- goscope, we can see that the vocal cords are motionless and far apart; if there be any movement, it is very slight, and connected with respiration.* The following is a case of nervous aphonia, due to lesion or functional dis- turbance of the superior laryngeal nerve. A young woman, aged twenty-seven, a shoe merchant, presented herself as an out-patient in the consultation-room, during May, 1863. She com- plained of an alteration in her voice, which was very hoarse ; and when she attempted to utter the higher sounds, she suddenly lost her voice alto- gether. Dr. Krishaber examined her with a laryngoscope in the presence of myself and my clinical class. He found that the appearance of the larynx was healthy. The formation of the epiglottis was normal, the vocal cords were of their natural whiteness : the other parts of the larynx were slightly discolored, but with this exception presented no lesion of any kind. When the patient emitted sounds, the vocal cords were distinctly seen during deep inspiration, normally to approach or retire from each other, performing their functions in the natural physiological manner. It was observed, however, that during the emission of sounds, the vocal cords did not oscillate and vibrate upon the glottis, in so distinctly visible a manner as when the organ emits natural sounds. The patient was quite unable to utter the higher sounds. This patient was pale, and not quite regular in her periods; but she had no symptoms of hysteria or chlorosis. Auscultation revealed nothing ab- normal in the state of the lungs: the heart presented no morbid sign, except a slight clatter of the valves. All the functions were naturally performed, and hoarseness was the only symptom of which the patient complained. She positively denied having ever had any specific diseases. Examination of the external and internal genital organs disclosed no trace of antecedent lesion, except a perineal cicatrix, the consequence of a laceration during labor. In this case, I adopted the treatment which for so long a period I have been in the habit of employing. By means of a sponge attached to the end of a piece of whalebone, I applied a solution of sulphate of copper around the laryngeal opening. Soon after this cauterization, the voice returned. This was evidently a case of purely nervous aphonia: during phonation, the vocal cords perfectly approached each other, and normally retired during respiration, which proved that there was neither complete nor incomplete paralysis of the inferior laryngeal nerve. Although there was no oscilla- tory movements of the vocal cords, or if any, very slight, this was evidently the result of diminished tension of the vocal cords : there was an absence of the degree of tension indispensable to the emission of normal voice, and particularly to the articulation of the higher sounds. It appears, therefore, that in the case now under consideration there existed a functional change in the superior laryngeal nerve. I ought to add that besides aphonia due to material lesions resulting from syphilis and tuberculosis, both morbid states produce a purely nervous aphonia. Pulmonary phthisis, for example, may, in its last stage, produce nervous aphonia, the consequence of general exhaustion of the system. The aphonia * Lagarde (L. Charles): De 1'Aphonie Nerveuse. \Thbse Inaugurale, 1865.] This thesis was suggested by the researches of Dr. Krishaber, to which the author constantly appeals. aphonia: cauterization of the larynx. 513 then shows itself with characters similar to that which is met with at the close of severe attacks of disease ; and there is an extinction of voice, just as there is an extinction of all the other functions. But likewise, and with- out any material lesion, as is shown by examination with the laryngoscope, pulmonary tuberculization sometimes produces nervous aphonia. Dr. La- garde gives an example of this, which was communicated to him by Dr. Krishaber.* In a phthisical young woman who had had aphonia for two months, the vestibule of the glottis, the aryteno-epiglottidean ligaments, the inferior vocal cords, and the margin of the ventricles of Morgagni were perfectly healthy. The vocal cords could approach each other, and yet there was no voice. There was, as I told you is the case when paralysis of the superior laryngeal nerves exists, neither vibration nor oscillation of the vocal cords. In eight days, however, the patient recovered her voice, without any special treatment having been adopted. She died two months later from the progress of the pulmonary phthisis. She retained her voice in its integrity to the very last, which is a proof that her aphonia was purely nervous. The laryngoscopic examination probably had some beneficial influence in re-establishing the voice in this case. Syphilis also, without there being any lesion, may cause aphonia. To this variety of syphilitic aphonia, Diday gives the name of secondary aphonia, to distinguish it from that which is met with in inveterate syphilis.f This kind of aphonia supervenes between the third and sixth month from the appearance of the first symptoms. It commences without pain or precur- sory symptoms. There is at first less fulness of voice, and the alteration afterwards proceeds gradually till there is complete aphonia. Nevertheless, there is neither cough, dyspnoea, nor any general febrile state. Diday has observed these symptoms both in male and female singers affected with syphilis. In such cases, fatigue of the organ is probably the exciting cause. Under specific treatment, recovery sometimes takes place in less than eight days. Hence, with Diday, we may ask, whether the affection is not simply a nervous disturbance of the functions of the larynx. In an abso- lutely similar case observed at the Hotel Dieu by Dr. Krishaber, and in which the voice returned at the end of eight days of mercurial treatment, there was no lesion discoverable by means of the laryngoscope. The case, therefore, was one of syphilitic nervous aphonia. Nervous aphonia is not uncommon in women suffering from disorder of the menstrual function. Such a case you had an opportunity of observing in a young woman who occupied bed No. 31 of St. Bernard's Ward-a case the history of which I shall by and by narrate. In relation to the subject of purely nervous aphonia let me recall to your recollection a girl of eighteen who came into St. Bernard's Ward in Decem- ber, 1859. Some months before admission, consequent upon a great fright, she suddenly lost her voice, and at the end of six weeks regained it, with- out having had any treatment. She had been ill for fifteen days, when she entered the hospital. She was working in a shop in the basement story, on a level with the street, when all at once a cart, with tremendous noise, smashed in the shop-front. The girl, struck with terror, fainted, and had a nervous attack : on regaining consciousness, she was voiceless. On the day after her admission, in presence of all the students, I cauterized the upper part of the larynx, with a saturated solution of the sulphate of copper : the voice immediately returned. Next morning, however, as there was * Lagarde : Op. cit. f Diday: Gazette Medicale de Lyon. T. xii, p. 35. vol. i.-33 514 aphonia: cauterization of the larynx. still some hoarseness, I repeated the cauterization, and the result was a radical cure. During 1862, you saw three young women enter our clinical wards, suffer- ing from aphonia ; one of them had been thus affected for two months. In all three, cauterization, practiced in your presence at the visit, almost com- pletely re-established the voice within a few minutes; and after four or five cauterizations, the functions of the larynx were restored to a perfectly satisfactory state. In June, 1863, you saw a girl of sixteen occupying bed No. 16 of St. Bernard's Ward. She is the patient to whom I have just alluded when speaking of the relation of aphonia to disorder of the menstrual function. When admitted, she had menorrhagic fever, accompanied by very acute uterine pains. Menstruation was easily re-established, but aphonia super- vened and lasted ten days, without being in any degree modified by the different therapeutic measures which I employed. In your presence, I cauterized the upper part of the larynx with a saturated solution of sulphate of copper, applied by means of a sponge attached to the end of a long piece of bent whalebone. The voice at once regained somewhat of its natural tone, and after the third cauterization was quite restored. In this case, laryngoscopic examination did not disclose the existence of any local lesion. However, in some cases, though the vocal cords do not in their whole extent approach one another during the emission of high sounds, there is apparently paralysis of their tensor muscles ; and in that condition, cauterization would seem to act as an excitant of muscular ac- tion. In this class of cases, Dr. Krishaber has sometimes been able to re- establish the voice by the introduction of the laryngoscope, as if a merely mechanical excitant sufficed to induce reflex action. When the laryngoscope discloses signs of acute inflammation of one or both vocal cords, or still more, when it shows that there is ulceration, the treatment which I have just been recommending, though efficacious, is not so marvellously powerful as you have often seen it in my hands : and frequently, when two cases have been seemingly identical, the revelations of the laryngoscope have explained why the result was not so satisfactory in one as in the other. Gentlemen, I cannot too earnestly recommend you to learn how to use the laryngoscope. But I must now return to my subject. It sometimes happens that individuals suddenly lose their voice after taking a cold bath, or after passing abruptly from one temperature to another. Sudden aphonia may also show itself consecutively to the sup- pression of a customary sanguineous flux; and one of the most common of this class of causes is suppression of the menses. The remarkable sympathy which exists between the genital and vocal organs is sometimes exhibited by the occurrence of aphonia during preg- nancy, after delivery, and in a still more general manner in the course of diseases of the organs of generation, especially in women, though the same remark is to a certain extent applicable to the male sex. It is in these different kinds of aphonia that cauterization at the lower part of the pharynx and upper part of the larynx has rendered me such unquestion- able services, after the total failure of all previous treatment. The prepa- rations which I employ are a saturated solution of the sulphate of copper, or a solution of nitrate of silver in the proportion of one part of the salt to five of water (by weight). The apparatus which I use for applying the solution is a piece of whalebone armed with a sponge, such as all of you have seen me employ in cauterizing the throat in diphtheria. I need not, therefore, now describe this little apparatus to you, which, moreover, as aphonia: cauterization of the larynx. 515 you all know, is exceedingly simple; neither is it necessary for me to-day to repeat remarks which I formerly made on the harmlessness of the ope- ration, seeing that it is now an operation within the ordinary domain of medical practice. The efficacy of this method of treatment may lead one to think that in these cases of aphonia, the mucous membrane of the larynx was the seat of slight inflammatory action, even though evidences of no such inflam- mation could be shown to exist; for in the cases which I have observed, there was neither pain, swelling, nor difficulty of breathing. But the bene- ficial effects of cauterization of the upper part of the larynx may be ex- plained by supposing that it produces a peculiar modality on the entire nervous system, and in particular on the nerves of the vocal apparatus. It causes a cessation of the spasm upon which the aphonia depends. However it may be explained, this sort of cauterization is still more useful in some cases in which the existence of inflammation is very obvious, and particularly in syphilitic laryngitis, in which there is no ulceration. The inflammation is characterized by pain in swallowing, in inhaling cold air, or in making an effort to speak. The efficacy of the treatment I am now recommending, and the rapid manner in which recovery takes place under it, seem to occur exactly in proportion to the superficiality of the inflammation, if one may be allowed to employ so incorrect an expression. In aphonia supervening as the sequel of a moral emotion, or as the result of abrupt stoppage of the menses, as well as in aphonia occurring during pregnancy or after delivery, one or two cauterizations generally suffice: and you have witnessed with what rapidity recovery took place after the first operation, in our two young women of St. Bernard's Ward. I have elsewhere pointed out to you that Mr. Green of New York not only applies the caustic to the entrance of the larynx, but even introduces into the cavity of the organ the little apparatus, consisting of a sponge attached to the extremity of a piece of whalebone suitably bent. As for myself, I often employ, for the same purpose, the instrument for applying caustic invented by Dr. Loiseau, which I described when lectur- ing on the topical treatment of diphtheria : it is much more reliable than Mr. Green's apparatus.* Prior to the discovery of the laryngoscope, be- fore the numerous useful applications of this instrument to the diagnosis and treatment of diseases of the larynx,f there was no way of reaching beyond the vocal cords and to attain even so far was attended by uncer- tainty and many difficulties. Now, however, it has become easy to see the lesions, and by practice one can very soon acquire the art of introducing surgical instruments and medicinal appliances into the larynx. Recovery is slower in the cases in which aphonia comes on gradually as a consequence of compulsory or excessive exercise of the voice. But aphonia associated with palpable inflammation of the larynx yields still more slowly. One remark more before I conclude! It might be supposed a priori, that inasmuch as aphonia can be easily cured by cauterization, it would be much more easy to cure a mere alteration of the voice characterized by im- possibility of producing certain sounds: but experience has taught us that, on the contrary, it is more easy and more satisfactory to treat complete than incomplete aphonia. * Loiseau : Bulletin de 1'Academie Imperiale de Medecine, t. xxii, p. 1138. Paris,. 1857. f Czermak : Du Laryngoscope et de son Emploi en Physiologic et en Medecine Paris, 1860. 516 DILATATION OF THE BRONCHI: BRONCHORRHCEA. LECTURE XXVIII. DILATATION OF THE BRONCHI AND BRONCHORRHCEA. Extreme Difficulty of Diagnosis.-Dilatation of the Bronchi may be mistaken for Pulmonary Phthisis, or for Pleurisy with Perforation of the Lung.- Differential Diagnosis.-Important Signification of abundant and Fetid Expectoration.- Causes of the Fetor.-Dilatation of the Bronchi, unless it be to a very great degree, is not a Serious Affection.- Treatment of Bronchorrhoea, or Pulmonary Blenorrhagia.-Balsams.-Arsenical In- halation. Gentlemen : The facts observed in early life are those which are the most permanently engraven on the memory: and very often, now that I am approaching old age, I recollect the most minute circumstances connected with cases of which I took down notes when on the threshold of my profes- sional career. In 1823, when I was still an hospital pupil, my excellent master Bre- tonneau had under his care a Parisian architect, who had long been an in- valid, and had been recommended to go to the Eaux-Bonnes by his medical attendant. At that period, there were no railways: the patient conse- quently posted, travelling by short daily journeys. The first halt was at Orleans, and the second at Tours. On arriving at Tours, he was so exceed- ingly fatigued as to be unable to proceed. Under these circumstances, he sent for Bretonneau. The appearance of the patient seemed to tell pretty plainly the nature of the disease under which he was laboring. Frightful emaciation, a yellow clayey complexion, continued fever, night sweats, and very copious muco- puriform expectoration, were the symptoms which he presented. Breton- neau felt almost certain that the disease was tubercular phthisis. Auscul- tation, however-then a recent art, which Bretonneau had studied with great enthusiasm-did not furnish the signs usually met with in phthisical persons. He neither found a dull sound on percussing the upper part of either lung, nor did he hear, as he expected, gurgling in one of the superior lobes. The patient died within a few days ; and at the autopsy, made with the greatest possible care, no trace of tubercle was discovered: Bretonneau recognized chronic inflammation of the bronchial mucous membrane; but he did not examine the tubes with a view to ascertain whether they were dilated in some places, or whether they were throughout of normal calibre. It must be stated that in those days, attention had not as yet been so much directed to the symptoms of dilatation of the bronchi, as it was in 1825, when Laennec published the second edition of his immortal treatise on aus- cultation. Laennec's description of dilatation of the brenchi is complete, although it was probably thrown off at the first dash. New facts have been added by the researches of Dr. Barth ; but he confirms, in almost every particular, the previous statements of the illustrious physician of the Necker Hospital. If you read the cases narrated by Laennec-especially his fourth case, to which he seems to attach most importance-you will become convinced DILATATION OF THE BRONCHI: BRONCHORRHCEA. 517 that it is exceedingly difficult to diagnose between phthisis and bronchial dilatation, by observing that the illustrious founder of the art of ausculta- tion hesitated, and, up to the autopsy even, remained in doubt: then, too, will you be better able to understand how Bretonneau's diagnosis was at fault in the case which I have just related to you. The first case in the excellent monograph of Dr. Barth affords testimony to the same effect. In 1835, Drs. Louis and Barth saw a woman die in their wards, whom both supposed to have had tubercular phthisis in the third stage, and yet at the autopsy, it was seen, that the tubercular lesions were quite unimportant, and had no possible relation to the very formidable symptoms which had terminated in death : but they found enormous bron- chial dilatations. Most probably, the morbid condition of the Parisian architect would have been proved to have been similar, had the attention of Bretonneau been directed to the subject now before us when the case came under his notice. First of all, then, gentlemen, it appears that certain attacks of bronchial catarrh may give rise to all the symptoms of tubercular phthisis: and I am only speaking of symptoms, for stethoscopic signs are generally absent, at least in cases in which the bronchial dilatations are not confined, as is sometimes observed, to the summits, or in others, in which dilatations exist both in the upper and central parts of the lungs: in such cases diagnosis is nearly im- possible. There is still another source of error, which has to be added to those I have mentioned. It sometimes happens that patients during the course of the catarrhal affection are seized with luemoptysis : and in place of quoting numerous examples, let me refer to Laennec's well-known case (Case 4th), in which upon two occasions the patient had spit blood within six weeks of his admission to the Hopital de la Charite, and to the seven similar cases which constitute the basis of Dr. Barth's memoir. A perfectly similar case, which has recently occurred in my own practice, I shall immediately bring under your notice. If you consider, that according to the testimony of Dr. Barth, bronchial dilatation exists on one side only in the majority of cases, that it as fre- quently occupies the summit as the base of the lung, and that the disease, when extensive, is very often accompanied by hectic fever, muco-purulent expectoration, and nearly all the symptoms of consumption, you will be a little more indulgent to those who make an erroneous diagnosis in such cases. It is true, gentlemen, that errors of this kind are not of very great im- portance ; for although we may sometimes be able to intervene usefully in cases of bronchial dilatation, the treatment does not materially differ from that usually instituted in tubercular phthisis. In fact the therapeutic indi- cations are the same ; such as moderating, as far as is practicable, the catar- rhal flux, the sweating, and the fever, sustaining the flagging vital powers, and, in a word, contending against the conditions more immediately dan- gerous to life which arise, leaving alone, as of secondary importance, the lesions against which our resources are impotent. Gentlemen, the remarks now made are not offered as the preamble of a bill of indemnity which I ask from you in respect of the young woman we have just lost in St. Bernard's Ward, whose case was one of the most re- markable examples of bronchial dilatation which I have had an opportunity of observing. The diagnosis, established with precision on the day of ad- mission, has been confirmed at the autopsy. I will admit, however, that sometimes my confidence in my diagnosis was shaken; and when the symp- toms of a hectic condition became more decided, and when the fetor of the 518 DILATATION OF THE BRONCHI: BRONCHORRHCE A. sputa increased, I became afraid that I had committed a mistake: several times I hesitated in my diagnosis between bronchial dilatation and pleural effusion communicating with the bronchi by a pulmonary perforation; but I reverted to my original opinion, thus giving you a specimen of uncer- tainty which would have been much greater had the principal lesion occu- pied the apex in place of the central and inferior portion of the lung. I shall now give you a summary of the history of this case. The patient was a woman of thirty years of age, little, thin, and puny, who, on 2d June, 1863, came to occupy bed No. 6 in St. Bernard's Ward. She had had a cough from her earliest infancy; and although she had never had an attack of asthma, was habitually out of breath. The menstrual function was normal, she had never had hsemoptysis, and no member of her family had had tubercular disease. She had had frequent attacks of inflamma- tion of the chest, accompained by severe stitches in the side. She had been confined twenty-one months before admission to hospital, and, till within a month, had nursed her infant. From that time, her cough increased : she had had constant fever for a fortnight, but till then, was able to attend to her household duties. This woman, as I have said, was thin : she had curving in of the nails- Hippocratic nails, as they are called-and yet her countenance was not that of a phthisical subject. Percussion below the spine of the scapula was very resonant: and the resonance was excessive at the middle and posterior part of the right lung, which was evidently dilated in that situation. Over the middle and inferior part of the left lung there existed, on the contrary, flattening of the thoracic walls, and well-marked dulness. No vesicular expansion, no expiratory murmur, nor blowing sound could be perceived on auscultating the supra-spinal and infra-spinal fossse. In the right subclavicular region, and there only, the expiratory murmur was slightly prolonged. But in the middle and inferior regions, along the left vertebral hollow, there were heard mucous rales combined with coarse gurgling and mucous blowing: the voice of the patient was so weak as not to be in the slightest degree resonant in that situation. Within twenty-four hours, the patient filled two or three spittoons with expectoration, which was purulent, semi- opaque, semi-salivary, somewhat frothy, and of a sickly, almost fetid odor. This fluid was brought up by an effort to vomit rather than by expectora- tion, after two or three fits of cough; and at each time two or three spoon- fuls were discharged. My diagnosis was-the existence of chronic bronchitis, and considerable bronchial dilatation at the middle and lower part of the left lung, and the absence of tubercles. I prescribed eight turpentine capsules, and fumiga- tions with arsenical paper. By the 7th June, the oppression in the breathing had increased, and on that day the fever was higher than on the previous evening. Very exten- sive fine subcrepitant rales-the rales of acute bronchitis-were heard. An emetic dose of ipecacuan was administered with the effect of produc- ing decided relief. Five days later, remarkable fetor of the breath was perceived, although there was not a corresponding fetor of the sputa. The pulse was 124, and the respiration 48 in the minute. There was orthopnoea. Over the right side generally, fine mucous rales were heard. An attack of acute bron- chitis had evidently become chronic. On the 12th June, at the evening visit, the pulse was 128: the respira- tion, which was very anxious, remained at 48: the skin was dry, and burn- ing. There was pain on both sides of the chest. On auscultation, fine DILATATION OF THE BRONCHI: BRONCHORRHCE A. 519 mucous rales were heard posteriorly throughout the whole of the right side : the rales were nearly crepitant, and dry at the base. On the left side, down to the middle third of the lung, there was gurgling along with blow- ing, and a somewhat amphoric sound of the voice, while fine mucous rales were audible at the base. Dry cupping with eight glasses, and an ipecacuan emetic afforded remarkable and almost immediate relief. Next morning, the fine rales, so distinctly heard on the previous even- ing, were no longer audible. There were no longer any vibrating rales. But in the evening, the fine mucous rales returned, and the respiration again became anxious. The ipecacuan was repeated, but not with the same suc- cess as on the former occasion. On the 15th, there was no increase in the frequency of the respirations, but the pulse was 140, at which it afterwards remained. On the 17th, rales, almost cavernous, were perceived at the external angle of the left scapula in the subspinal fossa: some of them almost had an imperfect sound of metallic tinkling. No change had taken place in the patient's general state, which was very bad. Slight perspiration was visi- ble on the forehead and front of the chest. On the 19th, there was slight sweating. The countenance was greatly changed, and had a pale bistre color. The voice was plaintive and feeble, but not extinct. The sputa, which had become as fetid as the breath, surged up in large quantities, filling four or five spittoons daily. On the 20th, the pulse was 148; and the respiration only 44. On the 22d, the face changed, the features becoming expressionless, the naso-labial groove deepening, and everything announcing that the end was near. On the 24th, death occurred. It is worthy of remark that this woman, who in the Grecian meaning of the term was phthisical, had never had the aspect of a person affected with tuberculosis, and had had neither colliquative sweats nor colliquative diarrhoea. We have just seen that the progressive wasting of the body and death necessarily resulted from the progressive and continuous diminution of the sources of hsematosis, and the enormous extent of the daily loss by bronchial suppuration. It may be asked whether pregnancy and prolonged lactation did not produce in this case of chronic bronchitis the same bane- ful influence which they cause in phthisis. The following is an account of the anatomical lesions met with in this case. The lungs were voluminous and very heavy; they did not collapse when the chest was opened. They were closely bound, particularly on the left side, where the pleura had nearly disappeared, to the parietal pleura, by very numerous adhesions. Similar adhesions united both pleurae at the part corresponding to the pericardium. There was no effusion into the pleural cavities. The adhesions were evidently the remains of the numer- ous attacks of pleurisy described by the patient when giving the historical details of her malady. The right lung, emphysematous throughout nearly the whole of its extent, was solidified in many places to such an extent that, notwithstanding the emphysema of which it was the seat, the pulmonary tissue presented a remarkable consistence. At the lateral surface of the inferior lobe of the right lung, a cavity was found capable of holding a small hazel-nut; its walls were soft, pultaceous, of a yellowish-gray, and yielded a gangrenous odor. Perhaps this explains why the breath was more fetid than the sputa. Around the excavation there was no tubercular deposit, but the surround- ing parenchyma, which presented a blackish-red color for about five mil- 520 DILATATION OF THE BRONCHI: BRONCHORRIKEA. limetres, had a density nearly equal to that of hepatization. Upon one of its walls, there opened the orifice of a small dilated bronchial tube. This small cavity was evidently not of tubercular origin, but the result of a pro- cess simultaneously inflammatory and gangrenous. There was no tuber- cular deposit at the apex, where the lung was exceedingly emphysematous ; it was slightly vascular, and immediately collapsed when cut into, as is the case in vesicular emphysema. When an incision was made into the pul- monary tissue, a liquid exuded similar to that which the patient ejected during life. The lower portion of the superior lobe presented incipient hepatization. The second and third divisions of the bronchi were much dilated ; their mucous lining was injected, and of a somewhat slaty color. The left lung had a solidified appearance, especially its posterior aspect, which was red and marbled; on moving the finger, however, over the middle part of the surface of this lung, places were met with which were very easily depressed, and were really caverns corresponding to the situ- ations in which gurgling had been heard during life. There were about twelve of these cavities, varying in capacity from the size of an almond to that of a walnut, filled with a whitish, cheesy substance, apparently con- crete pus. The membrane lining these cavities, so far from having the thickness and hardness belonging to tubercular cavities, was exceedingly thin. There opened into one of them a small bronchial tube, which was dilated throughout its whole extent. The pulmonary tissue intervening between the cavities presented the appearance of mere plates of conjunctival tissue, bloodless, almost transparent, and seemingly devoid of contractility. On making a section of the lung, through the assemblage of cavities, the appearance presented was that of a cut sponge, or to employ a still better comparison, of the lung of a batrachian reptile. Some of the cavities com- municated with each other, and were only separated by small imperfect partitions, resembling the valves of veins both in form and slightness. This alteration of texture has been specially described by Laennec. The presence of these cavities near the surface of the middle of the lung ex- plained the gurgling heard during life, on auscultation; and the large quantity of dense cheesy matter which they contained accounted for the dulness on percussion. Nearly all the bronchial tubes were dilated ; but one, of the second order in respect of calibre, going to the inferior lobe, was specially remarkable, from exhibiting about its middle an ampullary dilatation in diameter equal to that of the great bronchus: in the situation of this protuberance, the mucous membrane had a violet-red color. Most of the tubes which opened into the cavities already described as containing semi-concrete purulent matter were divisions of this enlarged tube. The superior lobe of this lung was a typical illustration of vesicular em- physema : it had a grayish-white color, gave to the touch the sensation com- municated by a down pillow, and collapsed when cut. Like the superior lobe of the right lung, it contained no tubercle. At the lower part of this lobe, there were seven or eight cavities similar to those so numerous at the middle and lower part of the inferior lobe of the same lung. The bronchial glands were very large ; when cut, they showed a blackish- gray appearance; and there was no trace of tubercle. To sum up the description: there was vesicular emphysema of the upper part of both lungs ; bronchial dilatation, and numerous cavities particularly in the middle and lower portions of the left lung; here and there, hepatiza- tion ; and nowhere, any tubercle. Such were the structural changes in the organs of haematosis in this patient, who scarcely breathed, except with the upper parts of her lungs-and these parts were emphysematous ! DILATATION OF THE BRONCHI: BRONCHORRH(E A. 521 You have all been struck with the extreme fetor of the breath in this case, which was almost intolerable when the patient coughed, and constituted a great source of annoyance to those who occupied adjoining beds; and yet it did not taint the expectoration. The sputa were diffluent, muco-puriform, and exceedingly copious, the quantity brought up in a day being at least a litre (rather more than an Imperial British quart) ; but their sickly and somewhat nauseous odor fell far short of the breath in disgusting fetor. There are two points of importance to consider in reference to the expec- toration-its great quantity and its fetor. I wish to discuss with you the great diagnostic value of both. Extreme fetor of the breath is observed in gangrene of the lung, and occasionally in tubercular phthisis, but in phthisis it is generally tran- sient, seldom lasting more than three or four days: in gangrene of the lung it certainly continues longer, particularly in that strange kind which attacks many lobules in succession; but in such cases, it is very powerful for some days, when it moderates and then returns as it was before, and again ceases to be powerful: these alternations, without the aid of any other signs, are quite sufficient to guide the practitioner to a correct diagnosis. There is something distinctive in the odor of gangrene: and in bronchorrhoea con- nected with dilated tubes, the smell is quite different, being suggestive of the presence of putrescent animal matter. I am aware that in successive lobular gangrene of the lung, the duration of the fetor may be considerable; and I recollect its continuing for nearly three months in a lady who was under the care of my accomplished friend Dr. Lasegue and me. But in bronchorrhoea connected with bronchial dila- tation the offensive smell continues for a very much longer period. In 1848, I saw in the Rue St. Ilonore, Paris, along with my honorable friend Dr. Louis, a man between sixty-two and sixty-three years of age, who had bronchial catarrh and dilatation of the bronchi. At the time when we were sent for to this patient, he had been seriously ill for several months, and after we had attended him for two months without his being benefited, he sought other advice. During the entire course of the disease, the smell of the breath was such as to render pestiferous the whole of his suit of rooms; and even the staircase leading to them was redolent of the same stench. I did not know what had become of the patient, I believed him to be dead, when, in May, 1863, that is, fifteen years later, I was sent for to see one of his daughters, from whom I learned that he was still alive, and still had a bronchial cough, which, however, except obstinacy, had no peculiar character. The persistence of fetor, when there is nothing else to lead to the belief that lobular gangrene of the lung exists, is in itself an important diagnostic sign of dilatation of the bronchi. Nevertheless, gentlemen, it may happen that for several months the expectoration is copious and fetid, although there is only a simple pul- monary catarrh : in some persons a common bronchial flux leads to conse- quences similar to those induced by certain fluxes connected with inflam- mation of a mucous membrane. It was the other day only, when speaking to you of ozaena, that I mentioned that in both sexes the gonorrhoeal dis- charge sometimes assumes an extreme degree of fetor, and also the flux in acute and subacute coryza, in circumstances in which it is impossible to assign the cause of this; and moreover, this stench is not always met with in the same individuals although placed under apparently identical con- ditions. In certain epidemics of influenza, or under the influence of the herpetic diathesis, for example, the bronchial flux in some persons acquires an extraordinary stench, which will continue during the continuance of the 522 DILATATION OF THE BRONCHI: BRONCHORRH® A. special phlegmasia on which the flux depends. This is perhaps the very thing which occurred in the patient mentioned to you in whom Dr. Louis and I suspected dilatation of the bronchial tubes, and who fifteen years sub- sequent to our forming this diagnosis was enjoying such good health as to lead us to suppose that we had erred in diagnosis; for it rarely occurs that bronchial dilatation diminishes as age increases. Gentlemen, if for several months, the expired air is continuously fetid, it is a diagnostic sign of great value in bronchial dilatation: copious expec- toration is not a less valuable sign. You have seen how much importance I attached to this sign, and how it has imparted confidence to my diagnosis. The diffluence and extreme copiousness of the sputa are hardly ever found except in cases of pleural vomica, unless we have to do with bronchial dilatation. Sometimes in the case before us, you have seen me hesitate, particularly when, during the patient's efforts to cough, the gurgling assumed the sound of metallic tinkling : nevertheless, I was brought back, in spite of myself, to my original diagnosis by the following special consideration. Undoubtedly, when a collection of fluid in the pleura .makes a way for itself into the bronchial tubes, a diffluent and very copious expectoration supervenes: but in such a case, the copiousness is sudden, on the day after its occurrence, it decreases, and although the quantity of matter brought up continues to be considerable for some days, after the lapse of that time, the copiousness is never so great as when the perforation took place, unless indeed there be hydro-pneumothorax, in which case enormous quantities of matter may for weeks continue to be discharged. Here, however, gentlemen, there is not much danger of confusion. The signs of hydro-pneumothorax, wThen the cavity is of considerable size, are unmistakable even by a somewhat careless physician; and when the mor- bid cavity is much circumscribed, the quantity of the flux is also much limited. You will recollect that when I was hesitating between belief in a pleuro-pulmonic perforation and a dilatation of the bronchi, I was always brought back to the latter view by the fact that I could never hear metallic tinkling, Hippocratic gurgling, nor tympanitic resonance in any part of the chest. I am well aware that a sign existed which greatly shook your confidence; I refer to the presence of dulness posteriorly of the affected side of the chest. This dulness which has been explained to you, not by condensation of the lung as pointed out by Laennec (and as is the general cause of dul- ness), but by the presence of an enormous quantity of semi-concrete matter in the ampullary cavities-this dulness I say, was not so complete in our case, and indeed never is so complete, as in pleurisy. But I quite under- stand that it may lead to an error in diagnosis, that it may lead to the be- lief that pleurisy exists, and so to the conclusion that there is a communi- cation between the cavity of the pleura and the bronchial tubes. Gentlemen, I have no intention of giving you in this lecture a complete account of dilatation of the bronchial tubes, a subject which you will find so well explained by Laennec, and by the later researches of Dr. Barth ; but I was unwilling to allow the case which has been engaging our atten- tion to-day to pass without pointing out all its clinical importance, and without making you aware of the magnitude of the difficulties with which the diagnosis of bronchial dilatation is surrounded. The lung which I showed you on the anatomical table is an example of bronchial dilatation in its extreme degree; and I do not believe that any case is on record in which this lesion has been found more extensive. Our patient was actually disfigured, so to speak, by the great extent of the structural alterations; and you would form a very erroneous idea of the DILATATION OF THE BRONCHI: BRONCHORRHCEA. 523 affection were you to regard the lung of which I am speaking, as a typical specimen of bronchial dilatation. Chronic bronchitis usually, and to a certain extent necessarily, causes vesicular emphysema. The vesicles and bronchial tubes, however, give way more easily in some subjects than in others : in the majority of cases, the vesicles become dilated, and the intervesicular tissue becomes con- densed : the dilatation of the vesicles may proceed to such a degree as to cause their rupture, whence originate the large vesicles which sometimes give to the human lung the appearance of the lung of a batrachian reptile, as was seen in so remarkable a degree in the case of our patient. In com- paring the lungs of patients presenting a very great degree of vesicular emphysema with lungs which are quite free from disease, a certain amount of attention only is required to perceive a fact which at a first glance might escape notice, viz., that besides the vesicular expansion, there is dilatation of the trachea and bronchial tubes: from the uniformity of the dilatation, it is the more apt to escape notice. The same remark is applicable to vesic- ular dilatation, when it is everywhere in the same degree: a certain amount of attention is then necessary to detect it, although the general enlargement of the lung, and its not collapsing, testify to the existence of the lesion. Bronchial dilatation may be, and in fact ought to be, regarded as an em- physema of the bronchial tubes. In most cases, it is equally distributed, and associated with vesicular emphysema: in other cases, it is unequally distributed, and then constitutes the affection known as bronchial dilatation, in which the dilated bronchi bulge out either into moniliform protuberances, having exactly the appearance of a string of beads, or, as is more usual, expand into elongated, fusiform, or ampullary shapes, as in the case now before us. Many of the bronchial cavities may communicate with one another, so as to give the lung the appearance of collections of united ab- scesses, or still more the appearance of certain multilocular ovarian cysts after they have been cut open and had their fluid contents evacuated. At the same time it can be seen, that the pulmonary tissue between the large cavities is condensed, a condition which explains the frequency of dulness on percussion, a common sign of extreme bronchial dilatation. I have often asked myself when looking at this induration of the lung, and at the evidences of chronic pleurisy, so commonly found at the autopsy, whether the large cavities in the pulmonary tissue were not real vomicae formed by the softening of the inflamed, suppurating lobules. When we come to study the lobular pneumonia of children, we shall see that it is very usual in that disease to find purulent collections of the size of a millet-seed or a lentil, or, exceptionally, as large as a small cherry. It is usual to admit in these cases-and as for myself I give my formal adhesion to the doctrine -that there has been an inflammatory melting down of a union of lobules, and the opening into the bronchial tubes of the little abscesses so formed. It is believed that the inflamed pulmonary lobule passes through all the degrees of hepatization to the third stage, to the stage of purulent soften- ing; and it is asked whether something analogous may not take place in the adult, in some cases of bronchial catarrh. The case now under review seems to indicate an affirmative answer to this inquiry: indeed, in some places, the lung has a greenish-black appearance, and is evidently sphace- lated. In bronchial dilatation, therefore, there are several degrees: there is that degree in which the air-tubes are dilated, and to which the term bronchial dilatation is properly applied ; while there is another degree in which lobules or parts of lobules are destroyed by compression or by the mere inflammatory process itself, which may produce ampullary cavities, 524 DILATATION OF THE BRONCHI: B R ONC HORRHCE A. hardly resembling bronchial dilatations, it is true, and being more like purulent cavities than dilatations. Whatever there may be in this opinion, an opinion which I would not ven- ture to maintain positively, and which rests on an examination of the path- ological anatomy of the parts, there still remains one peculiarity in this disease which I wish to point out and briefly illustrate. On reading the different cases which have been published, one is struck with the apparent harmlessness of the disease until it has nearly reached its last stage. The young woman with whose autopsy we are now engaged was not really ill till within a month of her death, for up to that period, though in precarious health, she went about her usual occupations. There was nothing in her condition to justify the belief that her end was so near. The aggravation of the symptoms came on rather suddenly, as also occurred in many of the patients whose histories have been related by Laennec and Barth. The celebrated subject of Laennec's fourth case did not discontinue work till within a few days of admission to hospital. Bronchial dilatation in itself, then, is only of secondary importance in respect of danger. Indeed, if you reflect upon the circumstance, that the local lesion is often so slight as to be limited to only one bronchial ramification, and extends sometimes only to as many tubes as in the aggregate do not constitute the hundredth part of the respiratory area, you will admit that occasionally it must be very diffi- cult during life to detect bronchial dilatation, particularly when there is a total absence of general symptoms. On July 2d, 1863, I received a patient, about sixty years of age, in my consulting-room. He came to consult me about a catarrh accompanied by oppression of breathing, from which he had suffered for more than two years. During the hour which he had to wait his turn for consultation, he filled a pocket handkerchief with copious diffluent sputa. He stated that he had often had slight haemoptysis, and that occasionally the expectoration became very fetid. He said that he had not had fever, and that his general state of health was not bad. I suspected that there was bronchial dilatation ; and on examining the chest, I obtained results which I shall now state. On the right side, there were signs of vesicular emphysema; on the left side, the lower half of the chest was to some extent flattened, and there was much less than the normal amount of resonance. On. auscultation, I heard coarse gurgling, with suction-sound and vocal resonance, similar to that which is so often observed at the summit of the lung in tuberculous subjects. The point in this case, gentlemen, to which I wish to direct your atten- tion, is the following: The patient walked, followed his usual occupations, and had no fever: although he had considerable bronchial dilatation, he did not suffer much, and his state was endurable, though he always had oppressed breathing and copious expectoration. When the dilatation is slight, it can hardly be called a complication, as it does not increase the danger of the bronchitis: but if it extend to an entire lung, and still more, if it extend to both, there is real danger, the causes of which are easily understood. First of all, the patient has availa- ble for the requirements of haematosis, only threeTourths, the half, or two- fifths of the pulmonary parenchyma. If, under such circumstances, an attack of bronchitis oi- pneumonia supervene, and respiration is without an apparatus, the patient necessarily dies. Ou the other hand, when we observe that a lung is in a very advanced state of bronchial dilatation, we have reason to believe that the pulmonary parenchyma surrounding the dilated tubes is the seat of chronic inflammation, which, under the influence of even slightly irritating causes, will become subacute. There is still another cause of danger which I cannot pass over in silence: DILATATION OF THE BRONCHI: BRONCHORRHOEA. 525 it is one which was apparent in the young woman whose case we are now considering. You saw the enormous pouches containing accumulations of semi-concrete pus, in appearance very like putty, and exhaling a frightful stench. I do not wish to affirm positively that the putrid discharge in contact with the diseased surfaces, and floating in the bronchi, carried by successive inspirations into the air-passages leading to healthy portions of the lungs, may not become a source of infection to the whole economy, a source all the more prolific, that the respiratory surfaces are of all parts of the body those which absorb with the greatest ease and rapidity, as is shown by the phenomena of respiration, by the sudden overwhelming effects produced by the inhalation of ether, chloroform, and some deleterious gases. Upon the whole, gentlemen, dilatation of the bronchial tubes is only a consequence, and one of the forms, of chronic bronchitis. I bring it promi- nently under your notice, because it presents symptoms and stethoscopic signs which deserve a little special attention. When bronchial dilatation has attained the point at which we found it in our patient, there is generally little to be done, and all our attempts are failures; but in the more usual form of the affection, the symptoms improve, and even disappear, when the bronchitis is cured. The fever ceases, the flux diminishes daily, and nothing remains of the affection, except habitual expectoration in the morning, which does not seem to affect the health. The treatment is similar to that which is employed in common pul- monary catarrh. In the acute stage, emetics are given: if there be high fever, digitalis is useful: when the oppression is urgent, ammoniacum, powerful remedies of the family Solanese, and the fumes of nitre, are indi- cated ; sometimes, we must rely on cutaneous revulsive measures, such as smearing with tincture of iodine, the use of carrot poultices, frictions with croton oil, and the application of flying blisters. But if, as often happens, the flux is excessive in quantity, there are new indications for treatment after the acute stage is over: they pertain to the bronchorrhoca oi'pulmonary blennorrhagia, regarding which I now proceed to make some remarks. In the case of a patient occupying bed No. 13 of St. Bernard's Ward, you heard me prescribe a potion of balsam of copaiba for chronic bronchial catarrh with copious mucous secretion, a form of catarrh which I have called pulmonary blennorrhagia. I must state my reasons for thus speaking and acting. Without at all instituting a forced analogy, we may say that catarrh of the air-passages, at least when accompanied by abundant mucous flux, admits of comparison with the catarrhal affections of the genito-urinary organs to which we give the name of blennorrhagia. Recollect that there are different kinds of blennorrhagia. There is one kind of blennorrhagia to which the name is specially applied, and the specific character of which no one will dispute: it is a contagious venereal catarrh contracted by sexual intercourse with a person who has the affection. But independent of simple venereal blennorrhagia, there is a form which is symptomatic of chancre in the urethra. It is syphilitic, and is a distinct species of blennorrhagia. Along with these two species of blennorrhagia there is another, which supervenes under the influence of connection with a menstruous woman, or with a woman who has leucorrhoea. This species is much rarer than some medical men believe, and much rarer than many patients allege. Ozanam, Blas of Magdeburg, and other trustworthy authors, have de- scribed epidemics of blennorrhagia occurring under certain medical con- 526 DILATATION OF THE BRONCHI: BRONCHORRHCEA. ditions of the atmosphere, in which the discharge lasted for some days, and then, as a general rnle, ceased spontaneously. Cases of rheumatic blennorrhagia are likewise recorded. It occurs in per- sons subject to arthritic pains, and in whom their sudden cessation has been followed by the appearance of a urethral discharge; or the reverse may occur, and the sudden stoppage of the urethral discharge may be followed by a return of the arthritic manifestations of rheumatism. In gout this occurrence is still more common. Swediaur recognized herpetic blennorrhagia: it is a species which per- haps is allied to the gouty. It is common in women, and rather rare in men. The influence of diathesis upon the production, form, and progress of blen- norrhagia is a subject which has recently been taken up anew and ably ar- gued by my pupil and friend, Dr. Peter. In a discussion »which he raised in the Medical Society of the Hospitals of Paris, this physician maintained that blennorrhagia is not univocal; that it appears and recurs most readily in persons of rheumatic, gouty, herpetic, or scrofulous diathesis: that in such persons it takes from the existing diathesis its specific characters, and consequently that along with, and in complement to, the topical treatment of the urethra, recourse must be had to the remedies which have been found useful in the cure of gout, herpes, and scrofula. Dr. Peter is far from sup- posing that when arthritis or ophthalmia supervenes during the course of an attack of blennorrhagia we have to do with blennorrhagic rheumatism or ophthalmia; and he considers it more correct to say that there is rheu- matic blennorrhagia, arthritis, or ophthalmia. He considers that the arth- ritic diathesis gives rise to all the complications, the blennorrhagia being only the exciting cause. The blennorrhagia itself could not be produced unless the diathesis existed. To this doctrine, which is essentially medical, I give my adhesion. It explains the failure which in certain cases attends the treatment blindly followed by specialists, and opens up therapeutic plans full of resources.* Hunter pointed out that among the complications which follow in the train of difficult dentition, there occurs a purulent discharge from the penis, accompanied by difficult and painful micturition, and exactly simulating a violent gonorrhoea. Some fermented drinks, particularly beer, when taken in too great quan- tity, are causes of blennorrhagia; and everybody admits the distinction which exists between this species of urethral catarrh and those other forms of which I have just been speaking. Finally, let me remind you that blennorrhagia is also sometimes the result of mechanical irritation of the penis, masturbation, or venereal excess, as well as of the other causes which I have mentioned. And to the same category belongs the blennorrhagia so frequently the sequel of the introduc- tion into the urethra, or the prolonged continuance therein, of a sound. In applying the term blennorrhagia to muco-purulent catarrhal secretions from the surface of mucous membranes, from the mucous membrane of the eye for example, it is necessary to distinguish different species, just as in blennorrhagia from the geuito-urinary organs. A child in coming into the world contracts a purulent ophthalmia from its mother who is the subject of vaginal blennorrhagia: that is a case of venereal ocular blennorrhagia. Another infant, born during the prevalence * Peter (Michel): De la Blennorrhagie dans ses Rapports avec les Diatheses Rhumatismale, Goutteuse, Scrofuleuse, et Paris, 1867. See also the " Union Medicale" for November and December, 1866; and February, 1867. DILATATION OF THE BRONCHI: BRONCHORRHCEA. 527 of an epidemic of puerperal fever, will take purulent ophthalmia of puer- peral character: that is a case of puerperal ocular blennorrhagia. There is a third species of ocular blennorrhagia which is very different from either of the two I have already mentioned. I refer to the catarrhal ophthalmia vulgarly called " cocotte "-that strange epidemic ophthalmia, equally prevalent among adults and children, which is characterized by a muco-purulent discharge from the palpebral conjunctiva. It is very differ- ent from the ophthalmia produced by simple mechanical irritation of the mucous membrane of the eye, caused by the presence under the eyelids of dust, snuff, or any other foreign body. Well, then, gentlemen, catarrhal affections of the pulmonary apparatus present an analogy to the catarrhal affections of other mucous membranes, to this extent, that in both we find different species, and that to all of them the term blennorrhagia is equally applicable. Attacks of pulmonary blennorrhagia may arise from simple irritation of the mucous membrane, such as those which supervene under the influence of the inhalation of cold air, or the vapors of chlorine, iodine, and arsenic. The irritation, after having in the first instance given rise to a slight muco- purulent discharge, produces (when it becomes more intense) a copious blennorrhagic flux, which may be compared to those which we have seen occur in the urethra and the eye-in fact, a true pulmonary blennorrhagia. Pulmonary blennorrhagia arises from very different causes. The cause may be the existence of that special, epidemic, and unquestionably con- tagious disease which we know under the name of influenza [grippe] : or it may be measles, which as you know is very often accompanied by a vio- lent catarrh characterized by cough and expectoration, the sputa often being muco-puriform, and so copious as to resemble the catarrhal affection in phthisis: or again, the pulmonary blennorrhagia may be a simple catarrh. I have no intention of giving you an account of these different species of catarrh. The similarity which I have established between them and urethral blennorrhagic discharges will suffice to explain the treatment which I instituted in the case of our patient in St. Bernard's Ward. The administration of balsamic preparations in the treatment of the catarrhal affections of the genito-urinary organs in both sexes is in the pres- ent day vulgarized to such an extent, that not only is it followed by nearly all practitioners, but it is even resorted to without medical advice by the majority of persons who find themselves attacked by urethral blennorrhagia, the medicine principally employed being copaiba. Although this drug is not an infallible remedy in these cases, the frequency with which it proves really efficacious is incontestable. A patient comes to consult you in a case of this sort: your first prescrip- tion embraces the use either of this medicine, or of turpentine, or of cubebs (which has properties similar to those of copaiba); while at the same time, you order some stimulating solution to be injected. Whatever may be the nature of the urethral catarrh, your treatment is pretty nearly the same; and cure, though it may be more or less delayed, according to the species of the disease, is always the final result. How does it happen, then, that pulmonary blennorrhagia is not more frequently treated by balsamic preparations, seeing that so much success attends their administration in urethral blennorrhagia ? We are too apt to imagine that the mucous membrane of the lungs being situated more in the interior, and concealed from our sight, is consequently more beyond the reach of remedies. There is nothing in this idea; and when we have failed to act upon the affection with our remedies, it is because they have not been properly administered. 528 DILATATION OF THE BRONCHI: BRONCHORRHCEA. Whatever may be the species of the pulmonary blennorrhagia, whether it depend on the specific catarrhal disease called influenza, or on morbil- lous catarrh, herpetic catarrh, or on catarrh of some other species, it will derive real benefit from the same medicines which are appropriate for the cure of urethral blennorrhagia. It is, however, perhaps, in cases of muco-purulent bronchorrhoea, cases in which it is not unusual to see the expectoration amount to several pounds in the twenty-four hours, with very little cough and no symptoms of irrita- tion-such cases as are particularly common in old people-that the bal- samic remedies (at the head of which I place balsam of copaiba and essence of turpentine) are most specially indicated. More than once I have met with this form of pulmonary catarrh closely simulating confirmed phthisis; and the frequency of this occurrence led physicians of old times to accord a very high value to balsamic remedies in the treatment of phthisis. It must be admitted, that in spite of all the improvements attained in our local means of diagnosing pulmonary phthisis, the symptoms of bronchor- rhoeal affections, usually accompanied by general or partial dilatation of the bronchial tubes, often mislead us still, not only when there is apparently a frightful amount of purulent softening progressing in the lungs, combined with the coexistence of nocturnal sweats, diarrhoea, and marasmus; but likewise, as I stated at the beginning of this lecture, in consequence of the bronchial dilatations sometimes furnishing on auscultation several of the signs looked upon as pathognomonic of the third stage of phthisis. It is proper to add, however, that in chronic catarrh, these signs are most fre- quently observed at the base of the lungs, whereas they are, on the con- trary, most commonly found at the upper part of the lungs when there are tubercles. The treatment of pulmonary catarrh by balsamic preparations is far from being a novelty. Dioscorides, who perhaps only repeated a fact in thera- peutics which had already been placed on record by Hippocrates, said that turpentine and the other resins purged the lungs of morbid matter. With- out, however, going so far back in the history of medicine as the times of Hippocrates, you know that Morton lauded the balsams, especially the balsam of Tolu, which is one of the ingredients of his famous pills.* At the beginning of this century, physicians, looking to the effects ob- tained from the balsam of copaiba in the treatment of urethral blennorrhagia, and attaching importance to the analogy which I have now pointed out be- tween catarrh of the lungs and catarrh of the genital organs, conceived the idea' of employing it in pulmonary catarrh. Halle has mentioned a re- markable example in which a patient suffering from chronic- pulmonary catarrh with copious expectoration of purulent appearance was cured by the balsam of copaiba. More recently the American journals published wonderful results obtained by Drs. Armstrong and Laroche by the use of similar means; while at the same time, in France, Dr. Avisard was showing the efficacy of turpentine. Gentlemen, you are acquainted with the manner in which these medi- cines-copaiba and turpentine-are most easily administered. To mask their disagreeable taste, they ought to be given in gelatinous capsules con- taining from 15 to 20 drops. Administered in this way, a patient may take from one to six grammes of either of these substances within the twenty-four hours. The ingestion of the medicines being accomplished in this manner, they * Morton : Phthisiologia ; cap. vii-De indicationibus curativis phthiseos origi- nalis. DILATATION OF THE BRONCHI: BRONCHORRIICEA. 529 are absorbed, their active principles are carried into the circulation, and exhaled from the surface of the pulmonary mucous membrane, quite as well as from any other mucous surface. The characteristic odor of the breath of persons taking these medicines clearly indicates that this statement is correct: moreover, the same odor is apparent in their urine and faeces, showing that the balsamic substances have also been presented to the genito-urinary and intestinal emunctory organs. These remedies, then, act upon the different mucous membranes when affected with catarrh in such a way as to modify their condition and determine a new state-a sort of morbid irritation-which brings to an end the pathological state, the mor- bid irritation of which they were the seat. Here, we have a substitutive treatment, similar to that adopted to subdue many other specific and re- fractory inflammations which we can cure only by substituting, by means of therapeutic agents, an artificial phlogosis with the nature and conse- quences of which we are acquainted. I have still a word to say, gentlemen, in continuation of my comparison of pulmonary with urethral blennorrhagia. When the latter is accompa- nied by violent inflammation which is propagated to the bulb, when there is chordee with ardor urinse, the balsams, acting more energetically than was expected, may exasperate the irritation of the affected parts, and prove more injurious than useful. In the same way, when in bronchial catarrh, the inflammation by extending to the pulmonary parenchyma, lights up a general febrile condition, balsamic medicines are contraindicated. Before we employ them in such cases, we must allow the inflammatory fever to subside; otherwise, we shall bring on complications of a character more serious than those which we desire to subdue. Besides the treatment which I have now been recommending, there is another method which you have seen me employ concurrently with it in bronchial catarrh. It is likewise topical, but it is more direct in its action than the treatment of which I have already spoken. I refer to the inhala- tion of medical substances, which bears the same therapeutic relation to pul- monary blennorrhagia which stimulating injections bear to blennorrhagia of the genito-urinary organs. These medicinal inhalations admit of being very much varied, both in respect of the substances employed and the manner of employing them. The simplest mode of administration consists in causing the patient to inhale air impregnated with balsamic vapors. To accomplish this object, you place in the patient's room vessels containing tar, on which, morning and evening, you pour a small quantity of essential oil of turpentine mix- ing it at the same time with the tar. By adopting this plan, the patient is kept constantly in a balsamic atmosphere; and to such an extent does absorption take place, that the urine acquires a violet odor. Inhalers have been invented to contain hot water, to which are added from fifteen to thirty grammes [about from 15 to 30 fl. drachms] of tincture of benjamin, and a little turpentine.* The most effectual method of bringing modifying medicaments into contact with the bronchial mucous membrane is to em- ploy the spray-apparatus invented by Dr. Sales-Girous, an instrument which you see in constant use in our wards, and by the aid of which, I be- lieve great service may be rendered in different affections of the respiratory passages. By using a fumigator or spray-apparatus you may obtain good results and vary your remedies. Some benefit may be derived from mercurial fumigation, accomplished by the patient inhaling the fumes of metallic mercury produced by throwing * Gaujot : Arsenal de la Chirurgie Contemporaine. Paris, 1867. T. i, p. 121. vol. i.-34 530 HEMOPTYSIS. mercury on a hot brick; but this proceeding has the drawback of frequently causing salivation. Finally, gentlemen, in the treatment of pulmonary blennorrhagia, great relief is obtained by smoking cigarettes of arseniated or nitrated paper. When I come to speak of asthma, I shall give you the formula by which to prepare them. The different methods of treatment which I have described, will enable you beneficially to modify the character of certain catarrhal affections accompanied by muco-purulent secretion, which, when neglected quickly become chronic, lead to dilatation of the bronchial tubes and vesicular emphysema, ending by being, if not diseases, at least serious infirmities. LECTURE XXIX. HAEMOPTYSIS. Haemoptysis.-Supplementary Haemoptysis.- The Differential Diagnosis be- tween the Haemoptysis symptomatic of Pulmonary Phthisis and the Haem- optysis of Hemorrhagic Pneumonia is by no means so easy as some physicians allege. Gentlemen : A short time ago, a girl of thirteen years of age, who occupied bed 32 of St. Bernard's Ward, died suddenly, death being the con- sequence of a terrible attack of haemoptysis, which occurred under circum- stances which I shall now relate. The patient was admitted to the clinical wards with pneumonia under- going resolution. Convalescence, however, was not thoroughly established. The continuance of the local thoracic signs heard on auscultation through- out a great extent of lung, particularly at the summit, and the persistence of the general symptoms of the fever of tubercular consumption, clearly testified that there was very far advanced phthisis. The disease, however, did not appear to be making rapid progress. For some days, the child had been in better spirits than she had shown since she came into the hospital, when, one evening about six o'clock, .nearly two hours after her evening meal, she was seized with a fit of coughing, and at the same time copious hemorrhage supervened, which led to death in less than five minutes. The patient, who retained consciousness to the last, stated that she felt herself to be dying. The blood, which issued copiously from the nose as well as from the mouth, was not frothy, and had a dark red, or almost black color: when it had coagulated in the vessel, it was black. The hemorrhage had more the appearance of hsematemesis than of haemoptysis. From the suddenness of the attack, the antecedents of the patient, and the rarity of hemorrhage from the stomach at so early an age, I concluded that the bleeding was from the lungs. In coming to this conclusion, I was also influenced by the recollection of similar cases, and in particular of one which occurred in the previous year in the same ward, the subject of which was a girl of the same age, and who likewise was suddenly carried off by a terrible attack of haemoptysis. At the autopsy, some might at first have supposed that I was wrong in my diagnosis, and that the young girl had died of hemorrhage from the stomach. In point of fact, the stomach was distended with blood similar HEMOPTYSIS. 531 in appearance to that which had been ejected during life : but we could find no lesion in the stomach. It soon became evident that the hemorrhage was bronchial. The lungs were riddled with softened tubercles, and in the upper part of both, there were extensive cavities: from both, when cut into, a large quantity of blood welled out by the ramifications of the bronchial tubes. No ruptured vessel was found; and, strange to say, the cavities did not contain blood. The hemorrhage was, however, not the less indubitably of pulmonary origin : blood was found in the stomach simply because the hemorrhage, being very great, had not sufficient way of exit by the mouth and nose, and the blood was consequently of necessity forced down the oesophagus. Gentlemen, this case, and others which I have seen in the clinical wards, have made me desirous of entering with you into some details relative to the diagnostic and prognostic value of haemoptysis. The first idea sug- gested by seeing a patient spit blood is, that he has tubercles in the lungs. Without thinking of his age, or the special circumstances in which he is placed, we are apt to jump to the conclusion that he has tubercles, and is the subject of a threatening phthisis. Nevertheless, if I were to reckon up all the cases of pulmonary hemorrhage which I have met with in hospital and private practice, I believe that I should find, that in the majority of cases, the bleeding did not depend on tuberculosis. However paradoxical this opinion may seem to some physicians, it is not the less a truthful state- ment. There is a certain class of cases of haemoptysis which is seldom met with in hospitals-cases in which the haemoptysis is the result of hemorrhagic deviation. We meet with women, subject to nervous attacks, who spit blood, sometimes in considerable quantity, though they do not experience any marked disorder of the menstrual function. Attentive examination of the thoracic organs reveals no lesion of the respiratory or circulatory apparatus. Neither do the patients present any symptoms of pulmonary or cardiac disease. When they reach the change of life, the haemoptysis ceases, never to return. There are also some women, who during pregnancy, and others, who during the whole time they are nursing, spit blood : the hemorrhage ceases spontaneously after delivery, or at the end of lactation, as the case may be ; and is not symptomatic of pulmonary tubercle nor of cardiac disease. You have had an opportunity of seeing a case of this kind. The patient was a nursing woman who came into our wards, after having had attacks of profuse haemoptysis at about the tenth month of an engagement as wet- nurse at Paris. These attacks recurred at very short intervals : the secre- tion of milk was dried up : the patient fell into an anaemic state : and I could not get rid of the idea of tuberculosis, although auscultation and percussion revealed no positive signs of such an affection. This woman left the hospital, to return to her native place. Two years afterwards, Dr. Blondeau had an opportunity of seeing her. She had then been for a long time in good health, and had regained a plump appearance, as well as a good color : she had recently given birth to a very healthy infant; and was again in a situation as wet-nurse. How are we to explain these cases of haemoptysis ? I cannot answer that question ; but I have now become sufficiently instructed in the subject by experience to be less alarmed than I used to be by haemoptysis super- vening in the circumstances we have now been considering. It is an inter- esting fact in relation to this class of patients, that they are generally ner- vous, and sometimes also subject to menorrhagia, at least to a very abun- dant menstrual flow. They seem to be under the influence of a hemorrhagic 532 HAEMOPTYSIS. diathesis, and when the normal crisis does not take place from the mucous membrane of the uterus, it takes place from the mucous membrane of the bronchial tubes. Although these bronchial hemorrhages are not such for- midable occurrences as one might be inclined to believe-although they may recur, at more or less regular intervals, during many years without occasioning danger-it must not be forgotten that their frequent recurrence causes congestion, which may give rise to inflammation of more or less dangerous character, and provoke diathetic manifestations which, were it not for the exciting cause, would not probably have been produced. When commencing practice, I used to be frequently called to a lady who had suckled four children, and had had violent attacks of haemoptysis during the lactations. For some years menstruation had been exceedingly profuse, a circumstance which made me uneasy about her. A long period elapsed before I could make out anything abnormal in the state of the uterus ; nevertheless, this patient died of uterine cancer. I may add, that she was rheumatic, and subject to serious nervous symptoms. As an example of haemoptysis coincident with a kind of hemorrhagic dia- thesis, I shall now relate a case. Among my old friends, there is a lady, who is the mother of an eminent physician. During childhood, she had had fits of somnambulism ; and ever afterwards, she was subject to nervous symptoms of the most curious description. At present, she still experiences, upon the slightest emotion, partial congestion of the skin, as is seen by its assuming a scarlet color lasting some minutes. Up to the time when the catamenia ceased, she was subject to menorrhagic attacks, which were often very alarming. When about thirty years of age, she had had such profuse haemoptysis accompanied by so great an amount of dyspnoea, that my ac- complished friend, Professor Andral, though unable to detect any signs of phthisis, judged it right to send her to the Eaux-Bonnes. This lady now has emphysema of the lungs. Age has deadened the nervous excitability, which in her earlier life was manifested by the phenomena which I have described, and although her health is far from being so good as could be desired, she still looks fresh and plump. Neither she nor her children have any symptoms to lead to the belief that they have tubercles. Haemoptysis besides proceeding from the peculiar condition or diathesis of pregnant and nursing women, may be to a certain extent a physiological occurrence, if such a term be applicable to a hemorrhage taking the place of a natural or accidental sanguineous discharge, which from some cause or other has been prevented from finding an exit by the usual outlets. Thus it is, that in women in whom menstruation is irregular or suppressed, haemoptysis is one of the most common forms in which hemorrhage occurs as a supplement of the menstrual flux. When in addition to the now described peculiar tendency in the economy, there is a local predisposing cause, it is obvious that the pulmonary hemor- rhages will occur still more easily. We can understand that such will be the case in women having pulmonary tubercles, heteromorphous products here playing the part of Van Helmont's thorn, and occasioning a state of congestion of which bronchial hemorrhage is the consequence. We have seen an example of this in a young woman, who occupied bed 25 bis of St. Bernard's Ward. This patient had been recently delivered, when she came into the Hotel-Dieu. She then was nursing an infant, very soon afterwards carried off by pulmonary phthisis, of which the mother her- self presented the symptoms and the signs. She had frequent cough, muco- puriform expectoration, fever, night-sweating, dyspepsia, and considerable loss of flesh. She had had antecedent haemoptysis. The physical exami- nation of the chest yielded, on percussion, a harsh sound at the right apex, HAEMOPTYSIS. 533 both before and behind : on auscultation, there was heard, in the same re- gion, prolonged expiration, moist crackling, and coarse raucous rales. These phenomena became modified : the patient regained a certain amount of plumpness, and her strength returned : where the local signs had been so well marked, there was now heard only feeble respiration, without any rales; the only remaining symptom was dyspepsia, indicated by a feeling of weight at the stomach after meals. This dyspepsia yielded to the administration of three drops of hydrochloric acid, which was taken daily in sugared water immediately after breakfast. I was hoping for, and even announcing, a speedy cure, when on the 18th May, the patient was seized with haemoptysis. She ejected blood from the mouth, which came up as if by vomiting: in the spittoon one could distinguish sanguineous sputa, frothy sputa of vermilion red, viscid, dark red, and black sputa, exactly like that which is character- istic of pulmonary apoplexy. For four or five days, there was a recurrence of the haemoptysis, which came on in the evening or during the night. It yielded, or at least it seemed to yield, to the use of terebinthinate draughts, decoction of rhatany, and eau de Rabel.* The patient, however, exhausted, and also alarmed by the loss of blood, again fell off in strength and plump- ness. Nevertheless, she was beginning to recruit, when, after the lapse of a month, on the 18th June, there was a recurrence of the hemorrhage, which returned repeatedly during two days. Having learned on this occasion that she had not menstruated since her accouchement, it occurred to me that the heemoptysis was periodical, and depended upon a hemorrhagic deviation. The first application of a leech to the inside of each knee prevented the return of the haemoptysis; but the sputa continued to be sanguinolent, and in color were like the lees of wine. The small local derivative bleeding was repeated on the 22d and 24th June, after which latter date, there was no more sanguinolent spitting. * You have observed that from that date, I watched the symptoms of uterine congestion. Every twenty or twenty-two days, this woman had slight headache, a feeling of weight in the lumbar region, pains in the hyp- ogastrium, and a more frequent desire to make water. You then saw me apply on three consecutive days a single leech to the inside of one of the knees. By this proceeding, I have been able to prevent return of the heemoptysis, and have seen a retrocession, or at least an absence of aggra- vation, in the pulmonary symptoms. The patient left the hospital, carry- ing with her the cause of death inevitable and probably near; but she left the hospital in infinitely better health than that in which she entered it. The differential diagnosis in this case, though difficult, on account of the pathological elements being so commingled, appears to have been justified by the mensual periodicity of the symptoms, and the success of the treat- ment employed. Professor Andral says that periodical haemoptysis in women having tuber- culosis ought not to be regarded as a supplementary hemorrhage, that it is associated with the existence of tubercle, and that its return no doubt de- pends on a more acute congestion taking place each month in the lungs, around the tuberculous masses.f * Eau de Babel is a mixture of sulphuric acid and alcohol, which takes its name from Babel, the person by whom its virtues were first extolled. It consists of one part of sulphuric acid to three of alcohol. The acid is added little by little to the alcohol ; and after eight days the mixture is decanted. It is given internally as a stimulant, tonic, and astringent, in doses of from 10 to 100 drops, in mucilage. Pure, it is a powerful topical styptic.-Translator. t Andrel : In a note at p. 307 of the 1st volume of Laennec's " Traite de 1'Auscultation Mediate." 534 HAEMOPTYSIS. This remark of Professor Andral does not appear to me to weaken the view which I have taken; for it remains to be asked, whether this more acute congestion which takes place each month ought not to be regarded as an accidental physiological action set up by the presence of the heteromor- phous products in the lungs, which play the part, as I have already said, of Van Helmont's thorn ; but which is dependent likewise on peculiar con- ditions which escape us,, and under the influence of which, irrespective of any tubercular affection, haemoptysis is produced, as a supplement to men- struation in women whose courses are irregular. Cases of this kind are not very common, but they do unquestionably sometimes occur. Be that as it may, one can see, that in similawnrcumstances, the prog- nosis of haemoptysis has a degree of seriousness very different from that of which I spoke when considering the hemorrhagic deviations which occur without local exciting causes. Here indeed, the symptoms are complicated by the local lesion which has produced them, just as the lesion itself is necessarily complicated by the existence of inflammatory congestive hemor- rhage which at each return must accelerate the evolution of hemorrhage. Supplementary hemorrhages are rare in hospital practice; but haemop- tysis symptomatic of tubercular phthisis is not perhaps the haemoptysis most frequently met with : the most common kind is that dependent on diseases of the heart. This remark must not be taken to imply that tubercular haemoptysis is absolutely less frequent than haemoptysis arising from cardiac disease. I merely mean to say that in tubercular subjects, the attacks of haemoptysis are transient, and occur at the beginning of phthisical disease, at a stage when the patients do not come into hospital. Haemoptysis, on the con- trary, dependent on cardiac lesion, occurs when disease is far advanced, and consequently at a time when the sufferers are obliged to seek relief in hospitals. Let us pause for a few minutes, to see if we can place upon a proper footing the differential diagnosis of the two kinds of pulmonary hemor- rhage of which I have been speaking. During youth, adolescence, and the first epoch of mature age-from the age of 16 to 40-haemoptysis is generally dependent on pulmonary tuber- cles. When met with during these periods of life, whether in hospital-or private practice, we may say in the words of the aphorism of Hippocrates " ab hcemoptoe tabes'' But after forty, and still more after fifty, it is, as a general rule, the sign of disease of the heart, and not of tubercular phthisis: at that period of life, even when the sputa have not that sanguinolent character attributed to apoplectic sputa, when they are of a vermilion color, frothy, or somewhat fluid, auscultation will disclose the signs of car- diac lesion. But in youth and mature age, though the sputa present the characteristics supposed to belong to the sputa of pulmonary apoplexy, though they are black, viscid, and unmingled with air (as is not at all un- usual and as sometimes occurred in the young woman with phthisis, whose history I have just related), the probability is that the haemoptysis is symp- tomatic of the presence of tubercles, and that, sooner or later, auscultation of the chest will give positive confirmation of that diagnosis. There are, of course, exceptions to these rules. Even in very young subjects, haemoptysis may be the consequence of disease of the heart, just as in old people it may be symptomatic of pulmonary tuberculization. These exceptions, however, do not weaken the general rule which I have stated. In pulmonary phthisis, sanguinolent expectoration supervenes either prior to every other manifestation of the disease, or after there is undoubted evidence of its existence. HAEMOPTYSIS. 535 Laennec regarded the haemoptysis of pulmonary phthisis as not profuse, as frothy, and as sometimes clotted, particularly towards the end of the attack. According to him, the very copious haemoptysis, in popular phrase- ology designated " vomiting of blood," is almost always due to pulmonary apoplexy. Professor Andral is opposed to this view, maintaining that the illustrious inventor of mediate auscultation had observed far fewer patients in his private than in his hospital practice, where, as I have said, tubercular haemoptysis is rarely met with. No doubt the quantity of blood lost in these cases is generally small, but there are terrible cases in which death is caused by the enormous extent of the hemorrhage. I have seen three cases of this kind; and the subject of one of them was one of the young girls to whom I referred at the commencement of this lecture. In her, the blood was frothy, and bright-red \rutilanf] when its flow was not profuse; black and clotted, when it was poured into the bronchial tubes too rapidly to be mixed up with the blood. In diseases of the heart, the consecutive haemoptysis is still less violent than bronchial hemorrhage of tubercular origin. We see cardiac cases in which the bleeding recurs on fifteen, thirty, or even fifty consecutive days, without causing death. Of course, if it depend on the rupture of an aneur- ism into the bronchial tubes, it proves more rapidly mortal than phthisical haemoptysis. I have already said enough to show you that the age of the subject, and the manner in which the symptoms advance, are important elements in the differential diagnosis which I am now endeavoring to establish between the two different kinds of haemoptysis. It is a noteworthy point in relation to the seat of the hemorrhage, that in phthisis the blood generally comes from the bronchial surface, and in heart affections most frequently from the parenchyma, taking place, in the first instance, into the vesicles of the lungs. Let us now study the distinctive characters of bronchial and pulmonary hemorrhage; and inquire whether their distinctive characteristics are as accurately defined as some maintain. Bronchial hemorrhage, it is said, occurs in the form of sanguinolent sputa, frothy, to a certain extent diffluent, and in fact presenting the appearance of whipped air and blood, or of the froth produced in a vessel into which an animal has been bled: it has a bright-red hue [une rutilance], which, to a certain extent, is regarded the classical sign of this kind of haemoptysis. Again, it has been said that sometimes the blood flows profusely-an opinion opposed to that of Laennec, as we have seen-and at other times in small quantity; that is to say, that sometimes the subjects of these accidents will for several days expectorate matter tinged with bright blood, while at other times they will seem to vomit a quantity of blood sufficiently large to abruptly terminate life. Finally, it has been said that in these hsemoptoic expectorations there is no admixture of food or mucus. It is much to be regretted that the characters are not always so well defined as now represented in description. Of this you will see a striking example in a woman occupying bed 27, St. Bernard's Ward. She is a phthisical subject, without any lesion of the heart, and has haemoptysis constituted of ropy sanguinolent sputa, such as are seen in the first stage of pneumonia, or in pulmonary apoplexy. This probably arises in her case and similar cases, from there being, in addition to the hemorrhagic affec- tion, a slight inflammatory action, which imparts to the sputa the viscidity characteristic of peripneumonia. Or, it may arise from the hemorrhage having been rather abundant, and the lung being, at the same time, suffi- ciently tolerant of the presence of the blood to allow it to accumulate and 536 HAEMOPTYSIS. remain for a certain time in the pulmonary vesicles. Under these circum- stances, should no new hemorrhage occur, the patient will, after a few days, bring up black sputa, and they will sometimes be as black as the sputa of pulmonary apoplexy. This color is explained by the sputa not having been in contact with air, which, when it mingles with the blood, renders it red and frothy. In cases in which the haemoptysis is unquestionably connected with tubercular phthisis, we find the expectoration mingled with portions of food, as in the case of the patient whose history I have given you. In that case, the spittoon contained sanguinolent diffluent sputa, mixed up with a con- siderable quantity of vomited food and mucus. The stethoscopic signs of bronchial hemorrhage are often at fault. Noth- ing more perhaps than mucous rales will be detected upon the most careful auscultation of a person who has been spitting blood for a long period. At other times we may hear subcrepitant or moist rales, attributable to blood in the bronchial tubes, but which, as they are also heard, when there is no haemoptysis, in the first and second stages of tubercle, are not of diagnostic value. To be of real diagnostic value, it is essential that the rales should not have been heard prior to the occurrence of the sanguinolent expectora- tion, and that when it ceases they too should cease. It is evident, therefore, that there are absolutely no stethoscopic signs of haemoptysis. The stetho- scopic signs which may belong to it belong equally, and indeed perhaps more, to the pulmonary lesion upon which it depends. Generally speaking, upon opening the bodies of persons who have died after having had attacks of bronchial hemorrhage, we find nothing more than the morbid appearances of phthisis, and a redness of the bronchial mucous membrane, due probably to imbibition. If cavities exist, they may contain a certain quantity of coagulated blood, particularly if the vascular ruptures have taken place in large cavities: under other circumstances there will be found little blood accumulated in the bronchial tubes. Before proceeding to the comparative examination of the sputa of pul- monary hemorrhage, I have a word to say regarding this affection, with a view to point out that it is a mistake, in my opinion, to employ pulmonary apoplexy as its synonym. Pulmonary hemorrhage generally supervenes during the progress of heart disease. On making the autopsy of individuals who have had this kind of hemorrhage, we generally find small portions of lung which are centres of congestion, as dark in color as the spleen, and as hard as pneumonic nuclei in their second stage. The lung tears under the fingers, and presents the granular appearance of hepatized tissue, with this difference, as Laennec remarked, that in inflammatory hepatization the vermilion color of the inflamed pulmonary tissue enables us to distinguish the black pulmonary spots, the vessels, and the slight partitions of cellular tissue which separate the lobules of the lung: but in hsemoptoic. engorgement the indurated part presents a perfectly homogeneous color, almost black, or very deep brown- red, which renders it impossible to recognize in the pulmonary texture more than the bronchial tubes, and the largest bloodvessels, the tunics of which have lost their white appearance from being soaked in and stained with blood. During last month you had an opportunity of seeing these anatomical characters at the autopsies of two of our patients who died from heart disease. In these cases the lesions were made known during life by the signs of that morbid state to which the name of pulmonary apo- plexy has been given, an objectionable designation for which sanguineous infiltration ought to be substituted. The affection has in fact no characters in common with cerebral apoplexy with which some wish to compare it: HAEMOPTYSIS. 537 the term apoplexy always implies the idea of sudden seizure and active con- gestion, characters belonging much more to bronchial than to pulmonary hemorrhage, which latter is usually more or less passive. It is true that cases have been recorded of true pulmonary apoplexy occasioning sudden death, and presenting at the autopsy more or less extensive effusion of blood into the middle of a lacerated lung, presenting very nearly the same appear- ance as cerebral tissue into which there has been violent hemorrhage. Apo- plexy is a term which would be much more applicable to active congestion of the lung, a disease which is not very uncommon, but which is very sel- dom accompanied by sanguineous effusion which can be properly called a hemorrhage. Dr. Gendrin* has substituted for pulmonary apoplexy the term "pneumo-hemorrhagie," which succinctly expresses, without any am- biguity, extravasation of blood into the tissue of the lungs. He rejects the term "apoplexy," because the invasion of the disease is seldom sudden, and is not accompanied by rapidly dangerous symptoms like those of cerebral apoplectic seizures-because the alterations of tissue differ in many respects from the alterations of tissue produced by encephalic hemorrhage-and because, in a word, it does not embrace all the forms and degrees of the pathological state in question. To return to the subject more immediately before us, let me ask: What are the characters of haemoptysis in cases of sanguineous pulmonary infil- tration ? We are told that the sputa are sanguinolent, copious, mixed with air and viscid like the sputa of peripneumonia, excepting that they are not frothy. This description may be considered as generally applicable. The sputa of parenchymatous pulmonary hemorrhage certainly are viscid and aerated, but have sometimes a bright-red color [coloration rutilante] like the sputa of the patient who occupied bed 17 of St.'Agnes's Ward, who, after having had attacks of pulmonary hemorrhage, sank under disease of the heart: sometimes they are blackish, or very deep red, a color which, as I have already remarked, is met with in certain cases of tubercular bronchial haemoptysis. The sanguinolent expectoration of parenchymatous hemorrhage may assume the appearance of bronchial hemorrhage in so far as to become frothy, a character dependent upon the quantity of blood which is brought up. Indeed, in contradiction of what has generally been said, it may be stated, that if the blood escape in small quantity, if brought up after having been slowly infiltrated into the pulmonary parenchyma, it is not frothy, because it is not mixed with air. But if the hemorrhage take place sud- denly, if the blood is thrown off pretty copiously, if it flow briskly from the bronchial tubes, it will be whipped up with the air therein contained, and in this way, the expectoration will become frothy. In the man of whom I have just been speaking, the haemoptysis presented this double character. There was some bright-red frothy sputa (exactly similar to the haemoptoic expectoration seen in phthisis) mixed with other sputa, which were viscid and of a darker color, while some were quite black. We shall find, on making the autopsy of this patient, that the opinion formed during life was correct, to the effect that his lungs are without trace of tubercle. In these cases of pulmonary hemorrhage, from the stethoscopic signs being so uncertain, and the diagnostic difficulties so great, Professor Bouil- laud has said, that the nature of the disease has to be divined rather than diagnosed. * Gendrin : Traite de Medecine Pratique, t. i, p. 638. 538 HAEMOPTYSIS. Should the sanguineous infiltration have been extensive, should large hemorrhagic nuclei exist, there will be heard, around the points invaded by the hemorrhage, local signs similar to those of pneumonia-a blowing sound, subcrepitant, and sometimes crepitant rales. Should the nuclei be circumscribed and disseminated, in place of being somewhat extensive, the blowing sound will be absent, and the rales only will be heard. These rales are caused by the exudation of blood around the hemorrhagic nuclei, and into the neighboring minute divisions of the bronchial tubes. Like the mucous rilles, they are produced by the passage of air through a liquid. These signs, which be it observed belong equally to congestion of the lung, to engorgement, or to catarrh of the small tubes, may be entirely absent: if the hemorrhagic nuclei are not only small, but situated at a distance from the surface of the lung, the most that we shall be able to hear will be coarse mucous rales in the large tubes. Cardiac lesions are very frequent causes of pulmonary hemorrhage: the cardiac lesion which is the most common of these frequent causes is con- traction with inadequacy of the mitral valve. The hemorrhage will be the more apt to occur, if, along with the lesion of the auriculo-ventricular orifice, there is, as is usually the case, hypertrophy of the ventricles. These hemorrhages are in some cases very considerable, and recur three, four, six, eight, or ten times in the course of the disease of the heart; in other cases, not often, however, they are insignificant in quantity, very transient, or altogether absent. When the cardiac affection is far advanced, the patients may go on spitting blood for a month, or even up to their death. I was lately seeing, at the Hotel des Princes, an American gentleman of sixty-five, who, consecutively to repeated attacks of articular rheumatism, became the subject of chronic endocarditis, with contraction of the auriculo- ventricular opening, and insufficiency of the mitral valve. He had had many attacks of haemoptysis which did npt continue more than a few days. Six weeks before his death, these attacks recommenced, and to the last, the patient brought up by the mouth every day four or five tablespoonfuls of blood. In this patient, at first, the signs furnished by auscultation of the lungs were negative: afterwards, we heard subcrepitant rales, and a slight blowing sound. These signs did not appear till near the close of life. The blowing sound was heard throughout the whole of the right lung. At the time I was attending the American gentleman, I was seeing along with another physician, a gentleman of sixty-four years of age, who had formerly come to me in my consulting-room. At the end of last autumn, he had been suddenly seized, after a hunting party, with difficulty of breathing and very acute pain in the region of the heart. The malady was almost overlooked by the patient, who did not give himself much con- cern about it. But from the symptoms becoming more severe he came to consult me. I had no difficulty in recognizing the existence of pericarditis, for the effusion into the pericardium was such, that, approximately, it might be estimated at half a litre [nearly 18 fl. ounces], due allowance being made for the extent of the precordial dulness and the degree of arching of the chest, as well as to the sounds of the heart being inaudible from their great distance from the ear. Under the influence of repeated bleedings, flying blisters, and the use of preparations of foxglove, the peri- carditis disappeared. Some months later, I could not detect the least sign of that affection; but along with the first and second sounds of the heart, I heard over the apex, a harsh blowing sound, which told me that there was a lesion of the auriculo-ventricular valve. For some days also the patient had haemoptysis, and in some parts of the chest I heard, on aus- HEMOPTYSIS. 539 cultation, subcrepitant rales and a blowing sound. My prognosis was unfavorable. After some deceitful rallies, this individual died like the American of whom I have been speaking. It is usual for these attacks of haemoptysis to become more frequent and more profuse, as the disease of the heart advances. I have now spoken of the different kinds of haemoptysis, and of the difficulty which often occurs in practice of distinguishing the one from the other; but I have still a few words to say upon the differential diag- nosis of haemoptysis and haematemesis. Gentlemen, I do not think that this differential diagnosis ought ever to be very embarrassing. It appears to me, that failing the precursory symp- toms, usually In themselves sufficient to inform the physician whether the blood ejected by the mouth has come from the lungs or stomach, there would still be no room for mistake, as the manner in which the blood is ejected and the physical characters which it presents are distinctively characteristic. It is said that haemoptysis takes place after efforts to cough : the blood then coming from the lungs is at the time of its expulsion fluid, red, and frothy; on the other hand, in haematemesis, the blood ejected by vomitive efforts is often set in coagulated masses, is black, and non-aerated. Further, it is almost always mixed with alimentary substances. Finally, this vomiting of blood-the haematemesis-is frequently followed by black stools, to which we give the name of melaena. While -it is quite true that in general the differential diagnosis of haemop- tysis and haematemesis offers few difficulties, there are exceptional cases in which hesitation is quite allowable. There may be something in the physical characters of the blood, and in the manner in which it is injected, to oblige us to hesitate in our diagnosis. I have already called your attention to the fact, that the blood may be black in haemoptysis when it is ejected very rapidly and with force. On the other hand, persons affected.with haematemesis may bring up perfectly liquid, bright-red blood. This occurs when, owing to the hemorrhage from the stomach being copious, the blood does not remain sufficiently long in the stomach to be acted on by the gastric secretions. We must not attach too much diagnostic value to the manner in which the blood is expelled, nor to the presence or absence of alimentary sub- stances, because, as I have already said, violent haemoptysis and vomiting take place exactly in the same way, without any preceding efforts to cough. In haemoptysis, patients frequently eject the contents of the stomach, true vomiting being excited by the efforts to expectorate, or by the titillation of the uvula causing sympathetic contractions of the stomach. On the other hand, in haematemesis, the blood may be poured out in perfect purity, unmixed with food, bile, or mucus. And this takes place, not only when the gastrorrhagia is consecutive to the rupture and perforation of a blood- vessel, but also, even when it is symptomatic of an organic affection, and not dependent on any appreciable vascular lesion. The melaenotic stools do not in themselves absolutely declare that the hemorrhage is from the stomach. No doubt, in haematemesis, the stools are nearly always black, but then they may also be black when the blood is primarily from the lungs, as it may have passed down the oesophagus into the stomach; as occurred in the young woman of St. Bernard's Ward, whose case I mentioned at the beginning of this lecture. Again, haemoptysis supervenes pretty frequently in patients who have neither tubercular nor cardiac disease. When speaking of bronchial dila- tation, I dwelt upon the fact that spitting of blood often takes place in cases in which, at the autopsy, no tubercles can be discovered. Haemop- 540 HEMOPTYSIS. tysis also, is often observed in connection with hydatids of the lung. We have at present an example of this in a young man of seventeen years of age who occupies bed 9 of St. Agnes's Ward. I can add nothing to what I have told you a hundred times about the treatment of pneumorrhagia or parenchymatous hemorrhage from the lung. When it is, as is usual, connected with disease of the heart, de- cided benefit is obtained by very moderate bleedings, the preparations of digitalis in full doses, acids, and rhatany. It is specially necessary to moderate the intensity of the determination of blood to the lungs, which, when it forms nuclei near the surface of the pleura may lead to inflamma- tion of that membrane, and become the cause of pleuritic effusion, consti- tuting a formidable complication of disease of the heart. You saw a case of this kind in a man who came into our wards in June, 1863.* When the- parenchymatous hemorrhage is obstinately recurrent ipe- cacuanha is a remedy which seldom fails. I am not at present referring to ipecacuanha administered as an emetic, which is more to be relied on in the treatment of what is called bronchial hemorrhage. You remember an old man, aged sixty-two, who lay in bed 7, St. Agnes's Ward. He was resident in the hospital from the beginning of 1863 ; and during the preceding year, he had asked my advice on account of his having serious symptoms of tubercular disease. For several years, he had been phthisical; and from time to time, the upper lobe of the right lung, in which there were large cavities, became the seat of acute inflammation, by which life was placed in jeopardy. Twice, within the space of five months, he had frightful haemoptysis : twice it was immediately arrested by four grammes [rather more than a drachm] of powder of ipecacuhan, administered within the space of half an hour, in such a way as to cause violent vomiting. A similar result was obtained, you remember, in the young man who occupied bed 8 in the same ward ; and also in another patient now occupying bed 16. Some months ago I was summoned in consultation to a provincial town, in the case of a tuberculous man, aged forty-two, who had had haemoptysis going on for forty days. A great diversity of very rational plans of treat- ment had, in succession, been fruitlessly employed. I recommended three grammes [46 grains] of ipecacuhan to be divided into four packets, one of which was to be given every ten minutes. The haemoptysis had ceased before the last vomiting took place; and from that time, when it did recur, it was only to an insignificant extent. Should, however, there be a relapse of the haemoptysis, the use of the ipecacuhan must be resumed. I never hesitate in such circumstances to return to it two or three times, if necessary, and I have never yet seen the least inconvenience result from this proceeding. Gentlemen, this is not a new method of treatment. For the last two centuries, physicians have lauded the Brazilian root as a remedy in all forms of hemorrhage; and Baglivi says: "Radix ipecacuanhce est speeificum et quasi infallibile remedium in fluxibus dysentericis, aliisque licemorrliagiis." Nevertheless, gentlemen, the hand trembles when it administers this rem- edy for the first time in the treatment of haemoptysis. We are accustomed to prescribe the greatest possible quietude to our haemoptoic patients: we counsel them to keep absolute silence: we tell them to restrain the slightest effort to cough : the very most we allow them to do is to breathe, and so frightened are we for congestion, even passive congestion of the lung, that we act as if we placed them in peril by permitting them to make the slightest * This case will be found fully detailed in the lecture on paracentesis of the chest, Lecture XXXII. PULMONARY PHTHISIS. 541 effort. Yet here we are giving a medicine which produces vomiting, during which the face swells, the blood stagnates in the veins by which it is being conveyed to the auricles: and consequently, the pulmonary veins become distended. One might expect that such treatment would cause the haem- optysis to return in a much more profuse degree; but in place of this, it is stopped in nearly every case. Here is one proof more of the small reliance to be placed on theoretical explanations, and of the value of empirical facts, without which, indeed, therapeutics would be a nullity. LECTURE XXX. PULMONARY PHTHISIS. Rapid Phthisis.-Acute Phthisis, or Galloping Consumption.- Rapid Phthisis is simply Ordinary Phthisis accomplishing its course in a very Short Period of Time.-Acute Phthisis is a Distinct Morbid Species, of which there are Two Forms, the Catarrhal and the Typhoid. Gentlemen: You have seen in bed 5, St. Bernard's Ward, a young woman between twenty-four and twenty-five years of age, the subject Qf rapid phthisis. Take special note that I do not use the term galloping phthisis. I purposely avoid employing that word. This does not arise from my having any repugnance to a universally accepted epithet, but because the epithet with a great many physicians has a meaning totally different from rapid. This, therefore, is a point upon which you are entitled to an explanation. Before I give it, however, let me succinctly recapitulate the history of our patient. This young woman was confined on the 14th March. When upon several occasions, I interrogated her regarding her antecedents, with a view to discover whether she had any previous symptoms of chest disease, she replied, that no one was less subject to catarrhal affections of the chest than she was. She said that from time to time, she had colds in the head, but had never had cough. She became pregnant eleven months ago, and during the whole of her pregnancy, she had remarkably good health. Labor was easy, and in all respects propitious. Some days after delivery, that is to say, on the 23d of last March-five weeks ago-she began to cough. From the first, her cough was severe, though it could not be called very violent. Not being able by any means to get rid of it, she resolved to come into the hospital. At my first visit after her admission, I detected by percussion a notable diminution of sound on the right side of the chest, posteriorly, in the infra- spinous scapular fossa, particularly between the scapula and the vertebral column. We also heard, by auscultation, in the same situation prolonged expiratory sound, almost bronchial blowing, mixed with moist rales. On the left side, the respiratory murmur and the thoracic resonance presented nothing abnormal. The patient had fever; but no night sweating, no morbid affection of the digestive canal, and no tendency to diarrhoea: on the contrary, she had constipation. What was the nature of this woman's disease? She had been ill for a fortnight. The signs furnished by auscultation and percussion led me to conclude that there was induration of the pulmonary parenchyma; but the 542 PULMONARY PHTHISIS. obscurity of the sound in the infraspinous scapular fossa, the moist rales, the prolonged expiration, and even the expectoration, which had the char- acters of phthisical expectoration, the globular, nummular sputa floating in nearly clear serosity-these signs were insufficient to convince me that the malady was tubercular. Such a conclusion seemed all the more unsound from the patient stating that a fortnight ago, she was in the enjoyment of perfect health, and that she had never had the slightest attack of chest disease. I was therefore inclined to believe that there was pneumonia of the summit of the right lung, although the elements of a cor- rect diagnosis were so incomplete as to cause me to have some doubt on the subject. However, by attentive daily auscultation, I found that the blowing, in place of decreasing, increased notably every day. The mucous rales became changed into crackling. Eight days after the arrival of this woman in our wards, I began to hear, on the left side, a little of the pro- longed expiration, and some subcrepitant rales: conditions similar to those on the left side were then recognized on the right side: expiration became more and more blowing : the rales became converted into crackling : and at last, we heard gurgling on both sides. Thus, an opportunity was afforded of being present to witness the advance of the disease: we saw the seizure take place in the hitherto healthy side, not as in pneumonia, but as in tuberculization. Hesitation as to the diag- nosis was no longer possible. It was only too evident that there was tubercular induration of the summits of both lungs, that phthisis progressing with fearful rapidity was threatening to carry off this young woman in a very brief space of time-perhaps in two months, in six weeks, or even sooner. That, gentlemen, is an example of rapid phthisis. Another example was lately presented to our notice in the youth who lay in bed 2, St. Agnes's Ward. The young man to whom I refer, who came into hospital on the 30th January, had no chest symptoms till ten days prior to that date: he died on the 25th March. A month before his death, and thirty-five days from the beginning of his illness-that is to say, on the 25th February-I de- tected hydro-pneumothorax, one of the most serious complications of pul- monary phthisis. At the autopsy, we found three perforations in the anterior and lateral part of the right lung, and in both lungs a vast number of tuber- cular masses of the size of a pea : there were no cavities. With the exception of the rapidity of its pace, this form of the disease, to which we apply the term rapid, presents the same symptoms during life, and the same anatomical lesions after death as ordinary phthisis, the prog- ress of which is generally chronic. It is the same disease as ordinary phthisis, though it generally runs its course with much more rapidity. There are also cases to which the term latent phthisis is given, because the symptoms remain obscure, and are masked by complications which are apt to lead us astray in our diagnosis. Nevertheless, whether the form be rapid or latent, regular or irregular, it is, I repeat, always the same disease. But acute, or galloping phthisis as it is more generally called, is not the same disease as ordinary phthisis. The anatomical character of galloping phthisis is the presence in the en- tire thickness and in every part of the lungs, from base to apex, of yellowish- gray, semi-transparent granulations. This specific character, recognized by men of high authority, by Rokitansky among others, is not denied by any one in the present day; but there is a great diversity of opinion as to the nature of these granulations. PULMONARY PHTHISIS. 543 According to some pathological anatomists, granulations differ in no respect from tubercles, of which they present the ordinary microscopical characters -they are " globules," to use Leudet's words, " round or ovoid, and angular in their outline, containing a more or less transparent matter, and molecular granulations ; and there is also, particularly in the semi-transparent grayish tubercle, an interglobular substance of a grayish-yellow color and tolerably firm consistence."* These authors, then, believe with Laennec that miliary granulations are tubercles in a less advanced state of development, and while they fully recognize the fact that galloping pulmonary tuberculiza- tion specially presents this form of semi-transparent, grayish, or nearly yel- lowish granulations, they likewise admit that it is altogether exceptional not to find, in addition to these granulations, traces of tubercle in a more advanced state of development, even cavernous ulceration. Finally, accord- ing to the same pathological anatomists, miliary granulations may exist in organs-in the bronchial and mesenteric glands, in the spleen, kidneys, and meninges of the brain-precisely as the yellowish tubercles of ordinary phthisis. But opposed to these pathological anatomists, others, whose opinions pos- sess unquestionable value, maintain that miliary granulations are morbid products quite different from tubercle. On this point, gentlemen, let me quote the views of a man, with whose high standing you are all acquainted. Aly accomplished colleague, Dr. Charles Kobin, in a manuscript note, kindly communicated to me in relation to some pathological specimens taken from the body of a patient who died in our wards, says, that under the name of miliary tubercle, four species of morbid products have been described. The first species, he says, consists of concrete pus. This was the species of miliary tubercle found in the patient to whom I alluded. The second is formed by epidermic products of the lung. These products are most frequently met with in children, particularly in infants at the breast; but they are also found in adults. Sometimes they are scattered here and there throughout the pulmonary parenchyma, and at other times, they exist in close contiguity to one another, being almost confluent: their starting-point is the pulmonary epithelium, just as in the parenchyma of glands, different affections have, as their characteristic lesion, augmentation in the quantity and volume of these organs. These epidermic products are the least common of the four species of morbid products now under review. A third species embraces the gray or semi-transparent granulations, iso- lated or confluent, in the latter case constituting what is called gray infil- tration. These gray granulations have a structure essentially distinct from that of tubercles. They occur in the form of isolated grains, deposited in layers, or in indeterminate masses: they are the same as granulations. The meningeal granulations met with in inflammatory affections of the meninges are sometimes tubercles; but more frequently they are the pecu- liar productions now under consideration. Granulations of the pleurae and peritoneum are of a different character. In these situations, this morbid product has been confounded with tubercle, even when examined by the microscope, by persons-observe ! it is still Professor Kobin who speaks-by persons under the influence of the old ideas of the school of observation, as it has been called, and who perhaps from neglecting to employ the reagents generally used, have regarded it as the corpuscle of tubercle, a special ele- ment, to which I shall return forthwith. It exists in a great number of in- flammatory and other products, such as the vegetations which form on the surface of wounds, and on syphilitic mucous patches. * Leubet: Recherches sur la Phtbisie Aigue chez 1'adulte. Paris, 1851. 544 PULMONARY PHTHISIS. The following are the anatomical elements of this granular product: 1st. The small spherical corpuscles of which I have been speaking; 2d. A very considerable quantity of amorphous substance, granular, semi-solid, infiltrated into the pulmonary tissue, and filling the minute sub- divisions of the respiratory passages ; 3d. Fibro-plastic elements; 4th. Granular bodies, to which the term inflammatory, has been given ; and 5th. A small quantity of epithelium coming from the minute bronchial tubes. It is a curious fact that occasionally, only occasionally, however, small masses of tubercle are found in the centre of these peculiar morbid products situated it may be in the membranes of the brain, in the pleurse, or in the lungs. This occurrence, I repeat, is not usual. It is chiefly observed in subjects who present large masses of gray infiltration. However small these tubercles may be, they have a yellowish color. They are always in- significant in quantity, as compared with that of the granulations. These granulations have no similarity in disposition with those which constitute the characteristic element of ordinary phthisis; and it would be an error to say, as has been said, that the former are merely the latter in a less ad- vanced stage. The latter never succeed the former species, galloping phthisis always proving fatal long before the tubercular deposit is abun- dant. Thus, gentlemen, you perceive that three species of morbid products are included in the improperly applied term, miliary tubercle, viz., concrete pus, epidermic productions, and gray granulations. The/ouWA species described by Dr. Robin is only a variety of the third species,-the gray granulations. True tubercle is sometimes found along with the products called miliary tubercles. Dr. Robin says, that however small the morbid products may be which contain the tubercular corpuscles, they have always the yellowish- white or yellowish-gray color characteristic of tubercle, and never the gray color of the products anatomically characteristic of galloping phthisis. When the naked eye only is used, there may be a difficulty of distinguish- ing them from concrete pus, but with the others, there is no risk of con- founding them: and by the microscope, they can be quite easily distin- guished from one another. In relation to the general disposition of these products, I must state, that from the autopsies I have had occasion to make, I have learned that when cavities are found in the lungs in galloping phthisis, they are simply small abscesses; and however large the cavities may be, they are never divided by bands or columns formed of shreds of cellular tissue. Again, it is im- portant to know that the glands are only attacked in exceptional cases. Putting aside the anatomical lesion, the nature of which is very open to discussion, the form of phthisis properly called galloping will be found to differ both from rapidly progressing and chronic ordinary phthisis. We shall see that the difference is still greater in respect of the symptoms than of the lesions. Some of you no doubt remember a young woman of twenty-one years of age, who lay in bed 10, St. Bernard's Ward. When she came into hos- pital, she had only been ill three months. Till then, the period at which she came to live in Paris, her usual health had been good. From that time, however, it was out of order: she had less inclination for food, and her strength was perceptibly failing. She continued, however, to attend to her domestic duties, till three weeks before admission to hospital, when she was PULMONARY PHTHISIS. 545 obliged to take to her bed. At that time, she had diarrhoea and colic: at first, the diarrhoea occurred at considerable intervals; but it soon recurred every day, and became profuse. At the same time, chest symptoms set in : she had cough and expectoration, but no spitting of blood: there was a great deal of fever. When she came into our wards, I was struck with her appearance of prostration and stupor. The fever was intense: the skin was hot and dry : the pulse was quick, full, regular, and not rebounding. There was profuse diarrhoea : the stools were yellow. Five days later, delirium supervened. There was a great deal of cough. Observing muco-purulent sputa in the spittoon, I was led to make a more particular examination of the respiratory apparatus. On auscultation, I heard posteriorly, disseminated over the whole of both lungs, coarse mucous rales, as well as sibilant rales. Anteriorly, percussion over the left clavicle produced the cracked-vessel sound [bruit de pot fele] : I found diminished thoracic resonance : I heard, moreover, coarse mucous rales, gurgling in fact, and at one point there was cavernous blowing. A few days afterwards the patient died. At the autopsy, we found such lesions as I have just de- scribed to you. What, then, gentlemen, are the symptoms of galloping phthisis ? A young woman-I say a young woman, for it is chiefly women, and chiefly young women whom I have seen the victims of this malady-a hitherto healthy young woman, without appreciable cause, falls into an uncomfortable state of health, which it is not easy to describe : she is dys- peptic, and loses her appetite: her strength flags, and a more or less fever- ish condition shows the disorder which pervades her system. This state of discomfort and languor lasts from a fortnight to three weeks or a month. During this period, the patient continues to go about her usual avocations, complaining, however, all the while, of unaccustomed weakness, and of great incapacity to do anything requiring mental application. She has at the same time night-sweats and a short dry cough : on auscultating the chest, we hear loud rales in various parts. When the symptoms have only existed for a few days, they are attributed to catarrh or slight bronchitis ; and in fact, there is nothing in the aspect of the case to lead to any serious apprehensions. But the catarrh goes on, and the fever continues. On examining the chest, it is found that the rales have become more numerous and more moist: they are heard throughout the whole extent of the lungs, from base to apex, before and behind. Time passes on, and matters, in place of improving, become worse : there is an increase of fever : there is insomnia : the cough, becoming more and more urgent, is accompanied by expectoration, which is at first mucous and then muco-purulent: the finest rales audible, the subcrepitant, are at some points mingled with prolonged expiration, and even with a blowing sound. The thoracic resonance on percussion remains normal. Respiration is embarrassed, short, and quick; and the dyspnoea increases to such an extent that the patient is obliged to keep the sitting posture. The symptoms go on increasing in severity : the strength becomes more and more exhausted : the countenance assumes an anxious expression : the discoloration of the skin is succeeded by an as- phyxial hue, and in five, six, seven, or eight weeks from the beginning of the symptoms, the patient sinks in a state of emaciation analogous to that which occurs during the course of severe fevers ; but in a state quite dif- ferent from the emaciation which attends ordinary phthisis. The picture of galloping phthisis which I have now rapidly sketched would be very incomplete were I to present it to you as the absolute type of the disease. It only brings before you one form, which may be called vol. i.-35 546 PULMONARY PHTHISIS. the catarrhal form: there is another, the typhoid form, which it is quite as important to be acquainted with. In the typhoid form, though we meet with the thoracic signs and symp- toms to which I have been directing your attention, it is the general condi- tion of the patient which characterizes his malady, and so closely does this general state simulate typhoid fever that the case may be mistaken for one of that disease. The symptoms complained of by the patient, and the phenomena observed by the physician, are intense headache, a stupid ex- pression of countenance, low delirium (changing sooner or later into more or less violent delirium), and frequently subsultus tendinum. The counte- nance in place of being pale is florid ; but the red is not confined to patches over the cheek-bones, as is remarked in the subjects of ordinary phthisis, particularly during the evening exacerbations of hectic fever. There is high fever, and the heat of the skin, which is not complained of by the patient, corresponds with the acceleration of the pulse. The abdomen retains its natural degree of softness and tension. Pressure made over the right iliac fossa does not produce gurgling: there is no diarrhoea : and it is important to note that there are none of the true rosy lenticular spots of dothinenteria. In the typhoid form of galloping phthisis, the invasion of the disease is generally more abrupt than in the catarrhal form, and its beginning is marked by more or less violent rigors. The course of the disease is also more rapid ; and it terminates by asphyxia or nervous seizures. In cases in which galloping phthisis simulates typhoid fever, examina- tion of the temperature furnishes us with a valuable means of diagnosis. It is only in exceptional cases, that the temperature is as high in acute tuberculization as in typhoid fever: the morning and evening oscillations too, are greater; thus, in galloping phthisis, the evening temperature differs one or two degrees from the morning temperature, while in typhoid fever, there is very seldom as much as one degree of difference between the tem- perature of the patient in the morning and the evening. Neither in the catarrhal nor typhoid forms of galloping phthisis, do you find, gentlemen, the symptoms of ordinary phthisis, even when the latter runs an exceedingly rapid course. There is, however, one point at which galloping and ordinary phthisis seem to have a connecting link: both attack persons in whose families tuberculosis is hereditary: at the same time, I must add, that they also attack those in whom no hereditary taint can be discovered. For the reasons now laid before you, one of my former excellent pupils, now my colleague in the Faculty of Medicine, as well as in the medical service of the hospitals, Dr. Empis, has come to the conclusion, that gallop- ing phthisis ought to be considered as distinct from tuberculization, from which he says it differs not less in respect of its lesions than of its symp- toms. With the view of fully preserving this distinction, he has given the name of granular disease [granulie] to the affection which is characterized anatomically by the production of granulations in the parenchyma or serous membranes. According to this doctrine galloping phthisis is the thoracic form of granular disease [la forme thoracique de la granulie] : the cerebral form is seen in brain fever or tubercular meningitis, and the abdominal form in cases having typhoid symptoms.* In galloping phthisis, the prognosis is death. Death, sooner or later, is invariably the termination. Hitherto, gentlemen, art has unfortunately proved unable to contend against this redoubtable malady: it is still more * Empis (G. 8.): De la Granulie, ou Maladie Granuleuse. Paris, 1865. PULMONARY PHTHISIS. 547 distressing to know that we have not the power even to alleviate the con- dition of sufferers by whom we may be consulted. I must give you the particulars of one more sad example of this disease: On the 2d February, 1861, my colleague Dr. Barth and I were sent for to Les Oiseaux convent, to see a young Spanish lady, sixteen years of age. Her ordinary medical attendant, Dr. Vosseur, informed us that this young lady had a fortnight previously begun to have uncomfortable feelings, and to suffer from fever, without experiencing any local symptoms, excepting decided oppression in breathing. As the symptoms continued, Dr. Barth was sent for, eight days later: at that visit, he was struck with the lividity of the lips and face. The lividity extended to both hands. There was great oppression of the breathing, and ardent fever. Nothing abnormal could be detected by the most careful auscultation : there was neither rale nor the sound of prolonged expiration. The functions of the stomach were as well performed as it was possible to desire. Eight days after that visit of Dr. Barth, I again met him in consultation on the case. There was then extreme frequency of pulse and respiration, and a frightful increase in the lividity of the skin. During the night, the patient had had insomnia and some raving. Throughout the whole extent of the left lung, we heard very fine subcrepitant rales: throughout the whole of the right lung, we heard coarse subcrepitant rales mingled with mucous rales: there was no expectoration. Our opinion was, that there was very little probability of the patient surviving more than three or four days. She died on the 4th February, seventeen or eighteen days from the be- ginning of the attack. Pulmonary Tuberculization, and Chronic Peripneumonic Catarrh in Children. Gentlemen ; Permit me now to fix your attention for a short time upon a little patient in bed 13 of the nursery attached to St. Bernard's Ward. For some time past his condition has been very anxious, and the diagnosis of his malady very embarrassing. This child is between seven and eight years of age. Since he was about three months old, he has had a severe catarrh, accompanied by fever, which has never left him since the catarrhal malady began. He has nevertheless continued to take the breast, and it is assuredly in consequence of his appe- tite for nourishment that he is still alive. He was brought here a fortnight ago. He had at that time a great deal of cough, and much oppression at the chest in breathing. On examining the chest I found tubal blowing on the left side, extending from the infraspinous fossa of the scapula to about the base of the lung, and resonance of, I cannot say the voice, but of the cry: the blowing and the resonance were well-marked, particularly during expiration. At intervals there exploded under my ear cracks of submucous crepitant rale, some of which were very fine. Comparative percussion, posteriorly, of both lungs showed us that there was very evident dulness on the left side. The child had fever. In consideration of the general symptoms and physical signs, I thought that the case was pneumonia, or rather pleuro- pneumonia : I believed that the lung was indurated, and that there was false membrane on its surface. But there was still a question to solve: What was the nature of the induration ? Again, was it recent, or of old date? And again, was the induration purely inflammatory, or was it asso- ciated with the presence of accidental products in the pulmonary paren- chyma ? Finally, had we to do with acute pneumonia, chronic pneumonia, 548 PULMONARY PHTHISIS. or tubercular pneumonia? The solution of these problems was attended with more than one difficulty. In children, particularly in infants at the breast, and during the first three years of life, the characters of pneumonia are different from those which the disease presents in adults. In the young subjects lobular pneu- monia, such as is observed in adults, is a very rare, and not a very serious affection; whereas peripneumonic catarrh, or bronchopneumonia, at a very early age, is one of the most dangerous diseases with which we are acquainted, inasmuch as it nearly always proves fatal. If you study catarrh, you will find out that there is no disease so uncer- tain in its course. It has no fixed limits of duration : it will sometimes con- tinue for thirty-six or forty-eight hours; and at other times it will go on, in an acute or subacute form, for two or three months. You never can tell a patient with catarrh when he will get rid of it; whereas, when the disease is pneumonia, it is more easy to give an answer. Generally speak- ing, in from nine to twelve days, pneumonia terminates in death, or the general symptoms improve, and convalescence begins. Do not suppose that the uncertainty which belongs to the course of catarrh is peculiar to bronchial catarrh: what I have said applies to catarrh in general, whether it affect the mucous membrane of the bronchial tubes, intestines, or bladder, or of the genital organs in either sex. That proposition established, you are able to understand that as catarrh is the starting-point of pneumonia in children, similar difficulties of prog- nosis will exist as in bronchitis: like bronchitis, it will maintain indeter- minate characters, and the same tendency to relapses, to which you can assign no term. A child is attacked with a severe feverish catarrh: at the end of four or five days, on auscultation of the chest, you hear disseminated over it sub- crepitant rales, and by and by a blowing sound: thus you arrive at the legitimate conclusion that there is pleuropneumonia. To subdue this malady, you have in vain had recourse to the most energetic medicines; and some days later the rales and the blowing sound, which had disap- peared, in a very short time will be again audible. You will find them in a different point from that which they previously occupied, whether that was in another part of the same lung, or in the other lung: very soon after- wards, without leaving the newly-invaded parts, they may occupy those where they were first heard. Such is the condition of the malady, the signs of which you will recognize much better by auscultation than by percussion, which will only tell you that an entire lobe, or a great part of a lobe, has been invaded. Thus peripneumonic catarrh may, within a few days, abandon the points which it first occupied and take possession of others, last of all, however, wholly disappearing; and thus peripneumonia may come and go successively for one, two, or three months. The successive attacks are not relapses, but returns of a cured disease. It is always the same in catarrh: the long series of interrupted and resumed symptoms which characterize it results from a similar cause. In the pure pneumonia of adults matters pursue an entirely different course. A lobe is attacked: the inflammation extends to the parts in the vicinity of these which were primarily and principally affected, but it does not leap from one point to another like catarrhal peripneumonia: it remains within the limits where it circumscribed itself from the first, or it advances step by step. There is no difficulty in understanding that in bronchopneumonia the pulmonary parenchyma, under the influence of the morbid action of which PULMONARY PHTHISIS. 549 it has been the seat during different attacks, permanently retains a more or less indurated state. Hence it is impossible to avoid admitting that bron- chitic catarrh will soon be accompanied by chronic pneumonia; also, let me add, that chronic pneumonia is a somewhat less uncommon affection in children than in adults. In the adult, chronic pneumonia is so rare, that (as you know), its exist- ence has long been disputed by a certain number of physicians. How- ever, the majority of clinical observers of the present day, while they point out its great rarity, hold that about the tenth or twelfth day of an attack of pure pneumonia, the general phenomena may disappear, the local symp- toms remaining. The fever subsides: the sputa regain their natural ap- pearance : and the appetite returns. Nevertheless, dulness on percussion remains: on auscultation, there is heard bronchial blowing, crepitant rales, bronchophony to a somewhat considerable extent; or-and many examples of this have been cited-neither normal nor abnormal sound can be heard in the seat of the lesion. This state of matters may last for fifteen, twenty, thirty, forty, and even for seventy days, as you will learn from a case de- tailed by Dr. A. Raymond in his thesis.* I should also wish, in relation to this topic, to recall to your recollection the man whom we had for so long a time in bed 19 of St. Agnes's Ward, who, at the date of his admission, had acute pneumonia in a very aggravated form. In this individual, for nearly two months, we noted subcrepitant rales, and a blowing sound, on the right side, in the infraspinous fossa of the scapula: he always retained a certain degree of fever: nevertheless, when he left the hospital, his health was quite restored, his respiration had become natural, and there was no longer any abnormal sound to be heard in the chest. It is evident that in this case, the inflammatory lesion, the induration of the pulmonary tissue, had persisted for a much longer period than is generally required for its resolution. The hepatization, doubtless, did not keep the same form which it had at the fourth or fifth day from the invasion.of the disease, but never- theless it continued to exist, and was quite independent of any tubercular affection. Chronic pneumonia has been correctly stated to be connected, not always (as those who deny its separate existence maintain), but almost always, with the presence of accidental products in the pulmonary parenchyma: or in other words, this form of pneumonia is almost always tubercular. This is true in respect of adults: it is also true in respect of children ; but in the latter, it is, speaking comparatively, a little more usual to meet with simple chronic pneumonia, that which terminates sometimes, though sel- dom, in resolution, but which under certain circumstances causes suppura- tion of the lobules, giving rise to small disseminated abscesses emptying themselves into the bronchi, their most propitious termination, or opening into the pleura, so causing very formidable symptoms. It sometimes hap- pens that these abscesses become encysted in the midst of lobules restored to a healthy state. Be reserved, even in respect of children, in stating your diagnosis, when the patient has been suffering for a long time from severe catarrh accom- panied by fever, if you have ascertained that bronchial blowing has been obstinately persistent at the same point for more than a month, and is accompanied by subcrepitant mucous rales, and does not depend on pleuritic effusion; be reserved in your diagnosis, for there is reason to fear that the child is a tuberculous subject. Tubercular disease is more common during infancy and early childhood, * Raymond (A.): Sur la Pneumonie Chronique. These de Paris, 1842. 550 PULMONARY PHTHISIS. than at any other period of life. Physicians who have had charge for a long period of institutions for infants at the breast know that most of their little patients die of tubercular disease of the chest. Unfortunately, the diagnosis of pulmonary tuberculization is much more difficult in very young subjects than in others. Many of the elements which auscultation can alone furnish to enable us to form an exact opinion as to the existence of the characteristic lesion are absolutely wanting. The vesicular murmur, the anomalous sounds by which it is replaced, or accompanied, are heard with difficulty, as children often breathe badly, and never breathe (as adults do) in accordance with your directions. The same remark applies to vocal resonance; for, as I have already remarked, the resonance of the voice is in children replaced by the resonance of the cry. The same remark is also applicable to auscultation of the cough, which is so often an assistance in the stethoscopic examination of the chest. We cannot count upon the ap- pearance of the sputa throwing any light upon the character of the dis- ease, because, as a general rule, children do not expectorate. If pulmonary tuberculization be so difficult of diagnosis in the child, how much more difficult will it be in the child to establish the differential diagnosis between tuberculization and chronic pneumonia, inasmuch as it is in many cases almost impossible even in the adult to distinguish between the two. I am aware that an attempt has been made to lay down characteristic signs, with a view to reach a solution of the difficulty. It is said that in the adult, the progress of the two diseases is different, and that purely inflammatory induration of the lung is generally the result of acute pneu- monia, and that tubercular induration arises slowly, and seldom follows pure inflammation. The value of the first test is obviously open to dispute, because it is by no means unusual for an attack of pneumonia to determine the manifestation of the tubercular diathesis in the lungs, and leave behind it induration of specific character. If the summit of one of the lungs is the chosen seat of tubercular indu- ration, we can generally by attentive examination detect something on the opposite side. In chronic pneumonia, the lesion is only on one side, and is generally at the base or middle of the lung. It was otherwise, however, in the patient in St. Agnes's Ward to whom I referred. In him, the lesion occupied that part of the lung, on the right side, corresponding to the infraspinous fossa of the scapula, that situation in which it is so common to meet with tubercular engorgement. The absence of haemoptysis in cases of chronic pneumonia, and their fre- quency in phthisis might furnish characteristic phenomena ; but we know how often we discover tubercular induration in persons who have never spit blood. General symptoms, such as rapid emaciation and night-sweats, which supervene in tuberculization and are absent in chronic pneumonia, are by no means unexceptionable differential signs, for it is not unusual to detect tubercles in their first stage in persons of apparently excellent health, and who only complain of a slight catarrhal affection : and we sometimes meet with others in whom there was nothing to arouse attention, but in whom, on careful examination, the presence of the serious and unsuspected disease was found. The resistance offered to the finger used in percussion, observed in chronic pneumonia as contrasted with the less complete dulness met with in tubercular induration, is another differential sign which has been mentioned; but it is one of so much delicacy, that I think it would be exceedingly difficult to prove its clinical value. To sum up: It is rather by induction, by an appreciation of the general GANGRENE OF THE LUNG. 551 character of the symptoms, by careful examination of the patient, by repeating the examination several times, and by watching the patient, that we can recognize the nature of his disease. We often learn more from the sequel of the case, and from supervening modifications in the phe- nomena recognized by auscultation and percussion, than from the previous history, or the facts we ascertained at the outset. In the child, the differential diagnosis is still more difficult than in the adult. In the adult, coarse mucous rales, gurgling, cavernous blowing- the signs of the formation of a pulmonary cavity, by the softening of tuber- cular deposit-when they follow blowing sounds and subcrepitant rales, give ultimately almost complete evidence of the existence of the tubercular affection; but in the child, these signs will not afford you any absolute certainty, because the coarse rales, gurgling, and cavernous blowing may be signs of the small pulmonary abscesses which are common in the pneu- monia of childhood, as well as of tubercular cavities. I repeat, however, what I have already said, that when you are consulted about a child who has been suffering for a long time from severe catarrh accompanied by fever, in whom you hear bronchial blowing which has been obstinately persistent for a month in the same situation, when the blowing is accompanied by subcrepitant mucous rales, and when you are sure that it does not depend on pleuritic effusion, do not pronounce an unreserved diagnosis; for there is reason to fear that the child is a tubercular subject. That is precisely the case of our little patient in the nursery ward. The duration of the symptoms for three months, and the persistence of the blowing heard upon his admission to the hospital, by making me at once reject the idea of acute pneumonia, and at the same time demonstrating the existence of chronic pulmonary induration, led me to the conclusion that there was tubercular deposit. LECTURE XXXI. GANGRENE OF THE LUNG. Difficulties of Diagnosis.-Several Species of Gangrene of the Lung: One of them, the Species here more particularly considered, is Curable. Gentlemen: I have to speak to you to-day of a patient lying in bed 1, St. Agnes's Ward. The pulmonary affection under which he is suffering has certain peculiarities which demand your earnest attention. This man, about fifty years of age, has long been subject to attacks of catarrh, which have often proved violent and obstinate. He states that upon one occasion, some years ago, the attack was complicated with symp- toms similar to the present. At the time he entered the hospital, some months ago, he was tormented by a frequent cough accompanied by catarrhal expectoration, which at first had nothing remarkable in its character in respect of the quantity and physical characters of the sputa. He was in a decidedly febrile state. In other respects, things went on with so much regularity as to give us no anxiety, when, quite suddenly, a few days after his arrival in our wards, he expectorated matter of so exceedingly pene- trating a fetor, that the nursing sister was obliged to keep the windows near his bed always open. All the patients in an adjoining ward, as well as in 552 GANGRENE OF THE LUNG. his own ward, complained of being poisoned by the horrible smell: and on one occasion, at the visit, I felt myself very much inconvenienced by his coughing. His breath and sputa diffused an insupportable gangrenous odor. After twelve, twenty-four, thirty-six, or forty-eight hours, the gan- grenous odor was replaced by a sickly smell of honey, very disagreeable, and perhaps constituting a specific character of the disease. These occurrences took place at intervals of a fortnight, eight days, or even of only four days: they were sometimes accompanied by fever of greater or less severity, or perhaps there was no fever at all. At each visit, I auscultated the chest with the greatest care, but I never heard gurgling, blowing, nor any sign of cavities in the lungs : I only heard sonorous rhonchus at the angle of the right scapula, and occasionally coarse mucous rales, which after being scarcely audible for twenty-four or forty- eight hours, all at once ceased. Percussion, however, elicited a very decided dull sound at the summit of the right lung, particularly behind. In the absence of stethoscopic signs of softening of the pulmonary tissue, and of a cavity communicating with the bronchial tubes, I was naturally led by the characteristic odor of the sputa and breath, to think of gangrene of the lung: but the progress of the symptoms, their intermittence, and the predominance of the catarrhal element, also told me that I had to do with one of those special forms of gangrene to which Dr. Briquet first called the attention of practitioners, and regarding which I shall immediately speak.* Gangrene of the lung has been rarely observed to follow pure pneumonia; and I have never seen a single case in which this has occurred. It was the opinion of Laennec that gangrene of the lung can hardly be placed among the natural terminations of pneumonia. But it may occur, when the pneu- monia is of a septic nature. By a curious chance the only two cases of gangrene of the lung which I have seen, presented themselves to me in my wards at the Hotel-Dieu within a fortnight of one another: the first occurred in a patient with malignant small-pox: the second, in a man with severe dothinenteria. I am not at present speaking of traumatic gangrene, to which attention has been directed, and of which you saw a case in bed 1, St. Agnes's Ward. This man was operated upon for empyema, and re- covered : I shall return to his case on a future occasion. Laennec believed that gangrene of the lung is generally allied in its nature to affections which are essentially gangrenous, such as anthrax, malignant pustule; and, as in these affections, the inflammation developed round the gangrenous part seems to be the effect rather than the cause of the mortification. Gangrene of the lung has been often observed in diabetic subjects: as you will see by the cases related by Griesinger, Monneret, Charcot, Marchal, and Fritz. There is here a sphacelus of the lung similar to that observed in the cases upon which Marchal (De Cal vi) has justly laid so much stress.f The bad general condition of the system induced by diabetes, produces necrosis in the pulmonary passages, just as it produces the same effect in the limbs, and in the crystalline lens in cases of diabetic cataract. Finally, I am inclined to think that pulmonary embolism may be the cause of more or less extensive gangrene of a portion of the lung, gangrene limited to the tissue in which ramify the branches and small ramifications of the obliterated vessel. This was evidently the case in a young woman, whom some of you may * Briquet: Archives Gen. deMedecine: 3me serie, T. xi. f Makchal (De Calvi): Recherches sur les Accidents Diabetiques. Paris, 1864. GANGRENE OF THE LUNG. 553 remember, who, in October, 1858, occupied bed 2, St. Bernard's Ward. She had been recently confined, and after delivery had had phlegmasia alba dolens. One day she suddenly complained of dyspnoea, and pain in the right side of the chest: the expectoration was very soon afterwards charac- teristic of the sputa in pulmonary apoplexy, and I entertained no doubt that the pain in the side, the dyspnoea, and the apoplexy of the lung were the consequences of an embolus. Some days later, the sputa were charac- teristic of gangrene of the lungs. The patient sunk rapidly. At the autopsy, I found sphacelus of that part of the lung supplied by the vessel in which the embolus was situated. When an opportunity occurs of re- turning to the subject of embolism, I shall give you, in extenso, the details of this case. For the present, I have said enough to convince you that gangrene of the lung may be .the result of an embolus in the pulmonary artery, although that vessel is not concerned in the nutrition of the organ. Afterwards, should an opportunity arise, I shall discuss this question in all its bearings; but at present, in support of the clinical fact, and to give it a more authoritative sanction, let me remind you that Virchow, in his experi- mental researches, has fully recognized this cause of gangrene of the lung. He says: " When the alterations produced by the embolus extend to the periphery of the lung, when the organ becomes gangrenous throughout a certain extent, the pleura.itself sphacelates in the part corresponding there- with, and then ruptures, giving rise to pneumothorax." This is what took place in the young woman, our patient; for besides gangrene of the lung, she had pneumothorax and gangrene of the pleura. I shall not dwell on this kind of parenchymatous gangrene, the history of which wTas originally written in a complete manner by the author of the Traite de 1'Auscultation Mediate. I shall only add, that among the causes predisposing to this affection have been mentioned excess in alcoholic stimulants, and inanition, the influence of the latter being very great. In- deed, gangrene of the lung is a pretty frequent cause of death in insane persons who have long refused to take food. Finally, let me remind you that hemorrhagic nuclei are frequently the starting-points of this kind of gangrene, as is shown by the cases published by Dr. Genest,* and by a case, still more characteristic, communicated to the Anatomical Society of Paris by Dr. Firmin. When I review the recollections of my personal experience, when I con- sult what has been written on this disease, I am struck with the inadequacy of the signs by which to determine the existence of gangrene of the lung. The stethoscopic signs are at first nearly the same as those which we find in cases of pulmonary abscess; at a later stage, when the portions of sphacelated parenchyma have been eliminated, the physical signs are exactly the same as those which reveal the existence of a cavity in the substance of the lung, whatever cause may have produced the cavity. The expectoration, though presenting something more characteristic, does not always furnish pathognomonic indications; it is only the odor which has a decisive import, for the aspect and color of the expectoration is exceedingly variable, and often differs in no respect from the muco-pur- ulent sputa of catarrh. The odor is sometimes absent at the beginning of the disease, and also at the end when there is a tendency to recovery. The peculiar gangrenous fetor of the breath is the only pathognomonic sign of gangrene of the lung. But even to this sign we must not attach too much importance, as it may signally deceive. I have several times seen circumscribed pleurisy, and * Genest : Gazette Medicate de Paris. 554 GANGRENE OF THE LUNG. particularly interlobular pleurisy, give rise to symptoms simulating gan- grene of the parenchyma. This occurs when perforation of the lung takes place. In a case of that kind the pus expectorated is small in quantity, and has at times a horrible fetor, auscultation furnishing the signs of a limited cavity. When speaking of dilatation of the bronchial tubes, I sufficiently insisted on the fact, observed by Laennec, that the pulmonary catarrhal affection sometimes assumes a strange fetor, well fitted to lead to the belief that it is gangrenous fetor. In certain persons, under the influence of violent inflam- mation, the secretion of the bronchial mucous membrane, like that from the nose, urethra, and vagina, has a disgusting smell, exactly like the gan- grenous odor; but as I pointed out to you in our patient, the fetor of the sputa, even when the gangrene is evident, notably differs from that which is observed in ordinary parenchymatous gangrene. It is principally in the peculiar species of gangrene of the lung of which the patient, the subject of the present lecture, offers an example, that the diagnostic difficulties are greatest. Here, in fact, the signs furnished by auscultation and percussion differ in no respect from those which charac- terize catarrhal affections of the lungs, viz., mucous rales, bronchial blowing (sometimes amphoric), bronchophony, all the phenomena dependent on pulmonary catarrh, on dilatation of the bronchial tubes, or on small cavi- ties. This arises from the fact, that in this particular species of gangrene of the lung, the affection does not involve the pulmonary parenchyma, but the extremities of the minute bronchial ramifications. Here, in fact, are the anatomical lesions mentioned by Dr. Briquet in the two cases constituting the basis of bis memoir in the Archives Generales de Medecine for 1841. The extremities of the bronchial tubes, dilated into pouches, form cavities on the surface of the lung, containing a viscid, grayish, very fetid liquid: the pouches are lined internally by a very soft, flaccid, whitish membrane, which can be removed by scratching, and which exhales a strong odor of gangrene. I was led to conclude that our patient had this particular form of gan- grene from the great similarity which his symptoms presented to those of which my friend Dr. Lasegue has drawn the picture.* A person of no particular age, of constitution more or less robust, a person generally speaking tried by previous hard work or much bad health, is seized with bronchitis, which at first has no special characters: the dyspnoea is not great, nor is the cough severe: the expectoration is pretty abundant, such as it is in the advanced stage of bronchial catarrh. The general health, however, shows a change for the worse: the sputa become more profuse and more purulent, and sometimes their fetor is such as to attract the attention of the patient and of those who are with him. This first critical period passes wholly, or to a great extent, without being per- ceived : the expectoration and the fetor diminish or disappear, the bronchitis however, remaining: there is little or no fever. After a period, varying in duration, the bronchitis seems to revive to a certain extent. The expectoration becomes greenish-yellow, sometimes brown, or at other times gray ; it again acquires a fetor which is peculiar and gangrenous: it increases in quantity, and may become exceedingly profuse. Usually, it occurs in fits during the daytime, in the morning, in the evening, or during the night, leaving intervals of rest to the patient, during which the breath retains more or less of its disagreeable smell: * Lasegue : Gangrenes durables du Poumon. [Archives Generales de MGdecine, 1857, t. ii.] GANGRENE OF THE LUNG. 555 strength diminishes, and there is less appetite: the digestive functions are not much disturbed, and there is little or no fever. On auscultation, we hear moist rales, coarse or subcrepitant, occupying a greater or less extent, persistent in some places, disseminated, mobile, accompanied or not accom- panied by bronchial resonance of the voice, and without decided dulness: at times, there supervene rigors of short duration, followed by profuse spitting: the cough has no specific character. This state of matters may go on from weeks to months, and from months to years, to the great detri- ment of the general health, which, however, while it becomes feebler, does not reach that state of hectic debility characteristic of advanced tubercular disease: there is little or no haemoptysis. Notwithstanding the continuity of the malady, its activity is suspended from time to time, the expectoration diminishing, for whether the amendment is persistent or temporary, it always begins by a diminution in the expectoration: the fetor gradually ceases, or suddenly disappears. During the intermissions, the stethoscopic signs become more faint, or are not at all changed. If the patient get a long period of repose, he seems to become quite restored: but if his rest be short, the economy hardly derives any benefit. Whatever may be the course followed by the disease, from this point of view, the bronchorrhcea is always an essential fact. It is excess in quan- tity, rather than the nature of the expectoration, which seems to exert a prejudicial influence. In the exposition now made of the phenomena which characterize this special form of gangrene of the lung, do you not find, gentlemen, most of the symptoms complained of by our patient and observed in him by us? Although presenting more than one point of resemblance to that form of gangrene of the lung which may be called the classical form, it essen- tially differs from the classical in being chronic in its progress, the other generally progressing in a more acute manner. It differs, too, in the pre- dominance of the catarrhal element, in the expectoration being always very abundant, and consisting almost exclusively of mucus of a fetid gan- grenous odor; while in gangrene of the parenchyma, the sputa usually assume an altogether special appearance of animal detritus. This form of gangrene differs from the other most of all in its being relatively a milder affection ; for although parenchymatous gangrene has sometimes a propitious termination, it is evidently cases of the kind we have now been observing together which have furnished most of the exam- ples of recovery. The cures have generally been obtained by pulmonary atmidiatria. As you are aware, atmidiatria is a method of treatment which consists in administering medicines by the respiratory passages : it is sometimes prac- ticed with a view to obtain a general action on the economy, as when chlo- roform is inhaled to induce anaesthesia; or, at other times, it is employed to modify an inflammatory state of the pulmonary apparatus. Inhalations of the vapor of turpentine-water have been found of real service in cases of gangrene of the lung, by Professor Skoda of Vienna, who was the first to praise them. I used them in the case of our patient, employing Richard's fumigatory apparatus. This instrument consists of a tin vessel, into which water is put, and then heated by means of a spirit- lamp placed below it. Within this tin vase is a large glass flask, to which two tubes are attached, and which is filled with tepid water, kept, by means of this water-bath, at a temperature between 45° and 50° C. The temper- ature is regulated by a thermometer placed in one of the tubes : to the other tube is adapted a bent tube terminating in the form of the beak of a clarionet. The patient puts this beak into his mouth, and through it in- 556 PLEURISY. spires air impregnated with the vapor of the water contained in the vessel, and charged with the medicinal substance. This instrument may now be replaced by the spray-apparatus of Sales-Girons, of which I have spoken to you on more than one occasion. ' The spray-apparatus allows, as you are aware, the vapor of the medicinal substances used to enter the deep recesses of the respiratory passages-not only the vapor of volatile substances, such as the essence of turpentine, the essential oils of cubebs and copaiba, which may also be administered by Richard's instrument, but it enables us to introduce into the lungs non- volatile therapeutic agents, provided they are soluble in water. In the form of gangrene of which I have now been speaking, I have also made use of preparations of tannin, of solutions of the extract of rhatany, of sul- phate of copper, of corrosive sublimate, of arseniate of soda-powerful modifiers, which, when introduced into the bronchial tubes, act upon the diseased surfaces in a manner wonderfully conducive to recovery. I need not say that at first the solutions used must be exceedingly weak, and that their strength requires to be slowly increased in proportion to the increased tolerance of the economy. LECTURE XXXII. PLEURISY: PARACENTESIS OF THE CHEST. Pleurisy.- Ordinary Signs.-Skoda's Bruit.-Interpretation of the Rubbing Sound.- Crepitant Rales of Pleurisy.-Persistence of Blowing Sound in Cases of Excessive Effusion.-Blowing Sound, and Amphoric Voice, are signs of Pleurisy.-Mistakes in Diagnosis may sometimes occur.-Inter- costal Fluctuation. Gentlemen : I readily admit that in the immense majority of cases pleurisy is an easily recognized disease. In proof of the correctness of that statement, I only require to remind you of the signs of the disease given by all your classical authors, and to which I never cease to direct youi' attention at the bedside of the patient. The stitch in the side, the cough, the absence of expectoration, the obscurity and then the dulness of sound in the parts most dependent, the increased volume of the chest on the affected side, the absence of thoracic vibration and respiratory murmur, the blowing sound, the segophony, the bronchophony, and other signs, are familiar to you. Nevertheless, in some cases, fortunately very exceptional cases, all the signs of pleurisy exist, and yet the autopsy reveals a different lesion. Quite recently, my colleague in the service of the hospitals, Dr. Empis, found all the signs of pleuritic effusion in a young woman, received into his wards at La Pitie, with pain in the right side, dyspnoea, and fever. Per- cussion elicited absolute dulness in the two inferior thirds of the right side of the chest: by auscultation, it was found that in the lowest part of the right lung there was an almost total absence of respiratory murmur, while in the two middle thirds, both before and behind, there was very loud bronchial respiration, accompanied by a considerable amount of aegophony. The patient died ; when it was discovered that the case was one of' enceph- aloid tumor, and that there did not exist the least effusion of fluid. Two PLEURISY. 557 years ago, the same physician communicated to the Medical Society of the Hospitals a curious example of hydatid cyst of the liver, which had pushed up the diaphragm and the lung in such a manner as to occupy the two inferior thirds of the right side of the chest, and so given rise to the signs of pleuritic effusion, though there was no effusion. I shall now quote the account of this case, which has been published by Dr. Empis. " When Dr. Monneret intrusted me with his wards, on leaving town for the holidays, he told me that the patient whose case is the subject of the following history was suffering from profuse pleuritic effusion, to effect the removal of which he had in vain exhausted the resources of medicine, and for which he thought paracentesis of the chest was indicated. He added, that he had attempted the operation some days previously, but having, as he had thought, made the puncture too low down, he had not given exit to any fluid, and had, he believed, penetrated the liver. He requested me to repeat the operation, and to make the puncture a little higher up. The existence of a pleuritic effusion did not seem to be a matter of doubt. There was bronchial blowing, and segophony, than which nothing could be more characteristic, at the junction of the superior third with the lower part of the chest. The patient was in a cachectic state, and was sinking day by day. I concurred in Dr. Monneret's opinion that thoracocentesis was indicated. M. Regnault, the interne, performed the operation in my presence, introducing the trocar between the fourth and fifth ribs: greenish pus immediately issued from the canula in such quantity as to fill the basin: then, almost of a sudden, this flow of pus ceased, and could not be re-estab- lished. The stethoscopic signs were little changed: bronchial blowing and segophony could still be heard, and the dulness had not diminished in pro- portion to the quantity of fluid which had been drawn off. We left the patient quiet for two days and then gave him an emetic : he brought up a great quantity of pus. The pus had evidently made a way for itself through the lung. Soon afterwards, the patient died. At the autopsy, we found that there was no trace of effusion into the pleura ; and that the disease was a large hydatid cyst of the liver which had suppurated, and which, from the enormous size it had acquired, had crushed up the diaphragm and the lung into the upper third of the chest, and so occasioned the dul- ness and the signs of pleuritic effusion which have been described. This case proves that bronchial blowing, segophony, and dulness are not always sufficient signs of effusion into the pleura, seeing that they may be produced by fluid encysted below the diaphragm pushing up the lung, and remaining in contact with it."* I have spoken to you a hundred times of the modifications which the signs of pleurisy may undergo in various patients compared with others; and in the same patient, according to the stages of his disease, as well as according to the quantity and nature of the effusion. I do not wish to go back upon these points to-day, and shall limit my remarks to some new signs, certain of which are universally accepted, while the value of others is still under discussion. Some years ago, gentlemen, the peculiar thoracic resonance described by Skoda [retentissement skodique] was recognized by very few physicians: at the present day, it is generally admitted, that in pleurisy, on percussing below the clavicle and in the region nearest to the sternum, there is heard a peculiar semi-tympanitic sound, to which my illustrious colleague of the Vienna School was the first to draw the attention of observers. * Empis : Bulletin de la Societe M4dicale des Hopitaux (Seance du 9 Oetobre, 1861). 558 PLEURISY. It is quite true that in some exceptional cases, where it is evident that there is only pneumonia, Skoka's resonance may be produced, as I have repeatedly pointed out to you at the bedside. Other physicians, among whom is Dr. Woillez, have arrived at the same conclusion with me on this point; but this sign is almost never absent in pleurisy, when the effusion does not come up above the fourth rib, and it is only met with exceptionally when pneumonia exists alone, uncomplicated with pleurisy. I must, however, gentlemen, somewhat limit the statement I have now made. I have told you that a patient may have pleuritic effusion, although by the most attentive examination we cannot hear blowing, segophony, or bronchophony; and when no other signs can be discovered, except dulness and absence of the respiratory murmur. I lately received in bed 6 St. Bernard's Ward a woman, who, along with serious lesions of the heart, had pleuritic effusion on the right side. Not finding the usual signs of the dis- ease, I carefully practiced auscultation every day, but I never once heard blowing, segophony, or bronchophony. Although there were no other phys- ical signs than dulness, with absence of vibration and respiratory murmur, I had no hesitation in affirming that there was effusion. At the autopsy, I found so great an amount of serous fluid in the pleura, that I exceedingly regretted not having performed paracentesis of the chest. You are aware that the friction-sound has been considered as a precious diagnostic sign of pleurisy. At the beginning of an attack, before any effusion has taken place, or while the quantity of fluid is as yet very small, the sound is supposed to be produced by the respiratory movements causing a rubbing upon one another of the two folds of pleura, the surfaces of which are covered with a thin layer of fibrinous exudation. Towards the close of the pleurisy, when the diminished quantity or complete absorption of the effused fluid permits the two pleural surfaces to come into contact, the fric- tion-sound is attributed to their being coated with false membrane, more or less thick and resisting. Gentlemen, the real friction-sound of pleurisy is much more rare than is generally said and believed. I have seldom had an opportunity of hearing it at the beginning of a pleurisy, a circumstance sufficiently explained by the fact, that I am seldom called in at that early stage of the disease; and that a few hours are sufficient to allow a more or less considerable effusion to take place. It is generally towards the end of the attack that we have the best opportunity of recog- nizing the sound produced by the rubbing of the pleural surfaces. I again repeat that this friction-sound is much less common than has been alleged. I wish to put an end to any misunderstanding with the physicians who do not concur in that opinion. In the first place, the kind of sound which is heard at the beginning of an attack of pleurisy, resembling the rustling produced by the friction of two sheets of very fine crisp paper, and to which the name of friction-sound [bruit de frottement] has been given, is in my opinion a blowing sound. I base this opinion on the following considerations. If you auscult your patient twice or thrice a day you will find that this alleged friction-sound becomes more and more harsh, till at the end of twenty-four or forty-eight hours, it has become a true blowing sound [veritable bruit de souffle] such as may be heaid in pneumonia. The voice at the same time has a distinct segophonic resonance, and, in proportion to the degree in which the friction becomes decided, the voice passes from a bleating bronchial resonance to a pure bronchial resonance [a Vegobroncliophonie, enfin a la bronchopltonie la plus nette]. I am consequently justified in declining to call the sound in PLEURISY. 559 question a friction-sound, and to regard it, with many other clinical ob- servers, as a modification of bronchial blowing. The friction-sound heard in the decline of a pleurisy also demands a few explanatory words. Quite at first, when coexistent with the pleurisy there is pulmonary emphysema or chronic bronchitis, we sometimes hear vibrating rales, which continue audible for a long time in the same part of the lungs, and which resemble so much, as to be liable to be mistaken for, the peculiar sound produced by rubbing the point of the finger on the hand when the skin is dry, or by pressing a bit of snow between the fingers; but if this sound at a determinate part of the lung, particularly in the ante- rior, middle, and lateral regions, if it continue to be found after we have made the patient cough ancl expectorate, it is hardly possible to confound it with a sonorous rale-it is then the friction-sound, the existence of which I never had the least intention to deny. Again, there is a sound of another kind which is heard at the end of a pleuritic attack, which has also been regarded as a friction-sound: it re- sembles fine crepitation, and is a very different sound from that about which I have been speaking. This sound, which is met with in the great majority of cases of pleurisy, is, in fact, a crepitant rale; and I have called it the crepitant rale of pleurisy. My interpretation of it is very simple. Just as we never have erysipelas without engorgement of the cellular tissue, there cannot be erysipelas of the pleura, or pleurisy, without an irritative en- gorgement of the subpleural cellular tissue or of the peripheric pulmonary parenchyma. This fluxion naturally carries with it into the pulmonary vesicles a serous exudation analogous to that of pulmonary oedema. We also meet with a fine subcrepitant rale, which is very often heard quite at the beginning of the pleurisy, and which likewise nearly always continues for somo weeks, when, the fluid being absorbed, there only remains sub- inflammatory oedema of the more superficial parts of the lung. I must not forget to mention a sign to which I have already often called your attention: I refer to the persistence of bronchial blowing and bron- chophony in cases of excessive effusion. I had long believed, on the state- ment of my teachers, and of the best authors on the subject, that the blow- ing disappeared when the effusion became considerable; but after I had many times performed the operation of paracentesis of the chest, I became convinced that not unfrequently, in cases in which the effusion amounts to several litres, and when the dulness extends up to the clavicle, when the diaphragm is pushed out of place, and the intercostal spaces dilated, bron- chophony and the blowing sound continue up to the very moment at which the trocar affords an exit to the fluid. You recollect that I have often in- vited you to ascertain for yourselves the presence of this sign ; and you also had an opportunity of observing, in the same cases, that when the puncture was made, there was a large quantity of fluid evacuated. Gentlemen, in cases of pleurisy we often meet with all the stethoscopic signs which belong to the third stage of tubercular phthisis. The attention of practitioners has been particularly called to this important point in diagnosis by Drs. Rilliet and Barthez,* Dr. Behier,f and (more recently) Dr. Landouzy.| It is now a recognized fact in medical science; and if-- * Barthez et Rilliet : Sur quelques Phenomenes rarement observes dans la Pleurisie Chronique. [Archives Gen de Mtdecine, March, 1853 ] f Behier: Note sur un Souffle Amphorique observe dans deux cas de Pleurisie Purulente Simple du cote droit. [Archives Gen. de Medecine, August, 1854.] J Landovzy: Nouvelles Donnees sur le Diagnostic de la Pleurisie et les indica- tions de la Thoracoeentese. [Archives Gen. de Mede cine, November and December, 1856.] 560 PLEURISY. as I am about to tell you-there is still a risk of committing great mistakes in diagnosis, it is not the less incumbent on us to bear in mind that till the publication of the researches of the physicians whom I have just named, this curious point in the history of pleurisy had not been well studied. Amphoric respiration, gurgling, and cavernous voice are sometimes so well marked, that it is impossible to avoid attributing them to the existence of cavities in the lungs, particularly when the sounds emanate from the summit of the lung; and even when they are heard towards the inferior angle of the scapula the same idea presses itself upon us, so identical seems the gurgling and blowing with similar sounds proceeding from largy exca- vations in the centre of the pulmonary parenchyma. But, nevertheless, the mode in which the disease commences and pro- gresses, the dulness of the dependent parts, the displacement of neighboring organs, the volume of the chest, the absence of lesions at the summit of the lungs, in a word, the general condition of the individual, usually enable us to form a diagnosis. However, it is sometimes difficult to avoid error. In the memoir of Drs. Barthez and Rilliet, you will find a very interesting case in which a mistaken diagnosis was formed by a very experienced physician. In acute or chronic pleurisy, what are the conditions which give rise to gurgling, and to amphoric breathing, voice, and cough ? Drs. Barthez and Rilliet, recollecting that in a case of pleurisy complicated with pneu- monia they had observed increase of the bronchial blowing, were led to think that in chronic pleurisy with bronchial respiration of cavernous tone, there existed, along with the effusion, more or less induration of the pul- monary parenchyma. Dr. Behier says that the amphoric sound is not heard in cases of effusion into the pleura, unless the lung, compressed and indurated, is in contact with the trachea or one of the large bronchial tubes. We can understand that the laryngeal sounds may assume an amphoric tone by transmission through indurated lung and through effusion com- pressing tubes of large calibre, such as one of the chief divisions of the trachea: then again, if the trachea or bronchial tubes contain a certain quantity of mucous secretion, the beating about of that fluid by the air will produce gurgling. This explanation given by Dr. Behier, and not very different from that formerly furnished by Drs. Barthez and Rilliet, is applicable to some cases, but not to all. It appears that when extensive effusion takes place into the cavity of the pleura, the lung, pushed up to the top of the chest and into the hollow of the vertebral column towards the root of the bronchi, is in a condition favorable to the production of amphoric sounds : but that nevertheless they are not always produced. It also appears, however, that amphoric sounds may be produced when the effusion is so small in quantity as to allow the lung to retain very nearly its normal relations. The case which I am now going to describe afforded you an opportunity of verifying this statement for yourselves. On the 14th April, 1862, a woman aged twenty-one, became the occu- pant of bed 30, St. Bernard's Ward. She had been confined at the hos- pital of Lariboisiere on an early day in November, 1861; and a few days after delivery, she had had some affection of the right side of the pelvis. This affection could not have been serious, for she was able to leave the hospital fifteen days after the birth of the child. From that time, she had fever and vomiting at each menstrual period. On the first occasion of my examining her, I discovered a large tumor in the right iliac fossa: it reached up, on both sides, to the crest of the ilium, and descended to the lateral parts of the pelvis, posteriorly enveloping the uterus, which was inclosed by it. The tumor, which seemed to me to be a pelvic abscess, very PLEURISY. 561 slowly diminished in size, and in a month had nearly disappeared. As it did not occasion any unfavorable symptoms, it was let alone, so that I might attend to the patient's other, and much more important, pathological conditions-conditions upon which I now wish to fix your special attention. On the 18th April, that is to say four days after admission to the hos- pital, our young patient complained of pain at a particular spot of the left side. Auscultation did not disclose to us any signs other than those of acute general catarrh. The chest symptoms seemed to be improving, when on. the 29th April, that is to say, nine days from the beginning of the bron- chitis and the stitch in the side, she showed evident signs of pleurisy on the right side ; and at the same time we detected an obscure blowing sound and subcrepitant rales over the angle of the left scapula. We had, therefore, a case of double pleurisy, complicated with slight bronchopneumonia. During the following days, the signs on the right side, which were those of pleurisy, viz., absolute dulness, bronchial blowing at the base, segobronch- ophony within the limits of the situation occupied by the effusion, became more and more decided: on the left side, I only found aegophony along the vertebral column ; but at the same time, I heard gurgling, and moist crack- ling such as is observed at the summit of the lungs when full of softening tubercular masses. While the stethoscopic signs on the left side remained without any sen- sible change, those which characterized the effusion on the right side became more and more decided. Paracentesis was resolved upon. The operation was performed by Dr. Dumonpallier, who followed the rules and observed the precautions which I have long ago laid dowm. Niue hundred grammes [about a quart] of a purely limpid serosity were withdrawn. The opera- tion was followed by a great amelioration in the state of the patient; but the serous effusion rapidly reaccumulated, and in four days it was necessary to tap a second time. It was the last time ; for there was no recurrence of the effusion: the dulness, however, continued up to the end, and eight days before death, there was heard slight aegophony near the angle of the right scapula. A few days after the operation, a new morbid cardiac sound was heard. On the 4th May, I began to hear distinctly on the left side, principally near the angle of the scapula, a blowing sound, amphoric respiration, and amphoric gurgling. From day to day, the amphoric, cavernous gurgling and respiration were objects of attention : they continued to be heard up to the death of the patient. Each day, five or six persons verified the stetho- scopic signs. Dr. Landouzy of Kheims, who was at the time on a few days' visit to Paris, honored me with his presence at the visit; and after examining the patient, had no hesitation in concurring with my opinion, to the effect that bronchitis and pleurisy existed on the left side. Pay particular attention to the fact, that while we heard mucous and subcrepi- tant rales in the middle and lower parts of both lungs, nothing of the kind could be observed in their summits. Upon comparing the signs furnished by auscultation and percussion in the case of this young woman, with the signs found in phthisical subjects, it will be seen, that there is no difference in the seat of the sounds. The expectoration was always that of bronchitis: there were no sputa coming from large cavities, nor was there any expectoration from pulmonary or pleural vomicie. The effusion was apparently diminishing, the dulness was not complete, and was non-existent above the inferior angle of the scapula, but the amphoric blowing and the gurgling continued in the dependent part of the lung, and along the vertebral column. The patient very soon had oedema of the extremities and puffiness of the face; but the urine did vol. i.-36 562 PLEURISY. not contain any albumen. She rapidly lost strength from intractable diarrhoea. The oppression in breathing became greater; and up to the evening before her death, the amphoric respiration and gurgling were heard in the situation already described. I shall at present only notice the anatomical lesions which were found in the lung. The right lung was, in its whole extent, adherent to the costal pleura : there was no trace of tubercle; and the bronchial tubes were filled with muco-purulent secretion. The left lung was elastic, free from all adhesions, devoid of tubercle and all other abnormal deposits. On making a section of the lung, muco- purulent matter flowed from the divided bronchial tubes. The sac of the pleura contained from 300 to 400 grammes [nearly a pint] of yellow serosity unmingled with fibrinous deposits: there was no false membrane on the surface of the lung. The pleural effusion then was inconsiderable, and the lung was hardly at all compressed, although the amphoric blow- ing had been heard on the evening preceding death. It must, therefore, gentlemen, be accepted as an unquestionable fact, that amphoric blowing may exist without the lung being indurated or crushed up in a mass [sans tassement] ; without there being any adhesions, or any pseudo-membranous deposits on the pleura ; and finally, without there being any compression of the large bronchial trunks. The gurgling sound, the seat of which was in bronchial tubes filled with muco-purulent secretion, was transmitted to the ear by superficial compression of the lung in the situation of the pleural effusion. It appears then, that other con- ditions besides those mentioned by Drs. Barthez, Rilliet, and Behier may give rise to amphoric sounds. It is curious to observe what takes place during the flow of the serum from the puncture made by the trocar, as well as what occurs subsequent to that operation. Proportionately to the escape of the fluid, the displaced organs resume their normal position : the chest tends to return to its natural shape; and very soon the play of the ribs and diaphragm is again seen. Skoda's resonance ceases, and the lung expands: although dulness is per- sistent over the greater part of the chest, we can discover, on applying the ear, rales of variable volume, rales deepseated and distant; and frequently, it is not till after the lapse of some time that the blowing and segophony disappear. Let me now state what is generally observed in cases of acute effusion, when the puncture is made ere the lung has contracted adhesions, and before it has become incased in thick, resisting, undilatable false mem- brane. In effusion of old date, the lung is enveloped in thick false mem- brane, the thoracic walls are immovable, and it is only the displaced abdominal organs which regain their normal position consequent upon the draining off of the fluid : the lung, impermeable to air, remains fixed in the vertebral hollow: rales are no longer audible: if blowing and segophony existed before the puncture, they remain, and are sometimes louder than previously. The enunciation of these phenomena, which are described in a memoir by Dr. Landouzy, show, that effusion of fluid into the pleura has not in itself the power to produce blowing sounds and tremulous voice. I am very far, therefore, from professing Laennec's theory, a theory accepted by all, which attributes the metallic tinkle, Punch and Judy tone, or goat-like sound of the voice, to the presence of more or less fluid in the pleura. But is it correct to conclude that the effusion has no part in producing bronchial blowing, amphoric blowing, and segophony? No: but the effusion operates in the production of these sounds only by com- pressing the lung, condensing it, so rendering it a better conductor of the sound produced in the bronchial tubes, or only transmitted by them and the trachea. The fluid, consequently, acts in the same way as false mem- PLEURISY. 563 brane, by tightly squeezing the lung, so that, in extreme cases of effusion, the blowing, as well as the segophony, are sometimes persistent. Let me remark, however, that bronchophony is more usually observed in these cases, and that it is the almost necessary companion of bronchial blowing. jEgophony, with its different modalities, is, nevertheless, a very valuable diagnostic sign in cases of moderate pleuritic effusion. Gentlemen, while in many cases of pleurisy, we find all the signs which belong to the third stage of tubercular phthisis, and while under such cir- cumstances an error in diagnosis is excusable, it also sometimes happens that patients presenting all the signs of that form of pleurisy on which Drs. Rilliet, Barthez, Behier, Landouzy, and I have so much insisted are really phthisical subjects, in whom the disease is localized in the middle and lower parts of the lung, and in whom there likewise exists chronic phlegmasia of the pleura, which is necessarily present when the tubercular lesion is in a very advanced stage. You no doubt distinctly remember a young woman who lay in bed 28 of St. Bernard's Ward, with whose case our attention was particularly occu- pied for a whole month. I shall now, in a summary manner, state the history of her case. The patient, eighteen years of age, who had been subject to cough for two months, but had only been confined to bed for a fortnight, was admit- ted to St. Bernard's Ward on the 23d May, 1863. The disease began like bronchitis with severe catarrh. There had been no haemoptysis. The fever was slight. The expectoration was mucous and scanty. There was a little pain on the right side of the chest. Diarrhoea, accompanied by abdominal pain, had existed for a fortnight. The resonance of the chest was normal on the left side, both at base and summit; but on the right side, there was complete dulness posteriorly of the two lower thirds, the resonance of the summit being good. Auscul- tation of the left side only revealed vibrating or mucous rales disseminated in the middle and inferior but not in the uppei* part of the lung: on the right side, at the summit, there were no signs more marked than those found in the corresponding region on the left side; but in the situation where there was dulness on the left side, that is to say about the middle of the chest, there were coarse rales, blowing sounds, and amphoric voice. The diagnosis was-general bronchitis, and pleurisy on the right side with amphoric sounds. This diagnosis was based on the progress of the disease, on the nature and small quantity of the expectoration, and on the seat of dulness and abnormal sounds. For a fortnight, matters remained in this position ; and at the end of that period, there was a marked increase of fever and diminution of strength. Mucous rales were heard at the summit of the left lung: but it was in the centre of the lung that the rales were most numerous and the bullae least voluminous: towards the base, they were as stationary as in capillary bron- chitis. On the right side, the respiration and the voice were amphoric. From the twentieth day after her admission, she had a paroxysm of fever every evening: her general state became very bad: her aspect was that of an individual with typhoid fever: she had headache, noises in the ears, deafness, and giddiness when standing upright. Her tongue was dry, and she had urgent thirst. She had passed her motions involuntarily for two days. On the 25th day, I heard on the left side, and for the first time, gurgling and amphoric blowing in the subspinous fossa of the scapula: some rales had an almost metallic resonance. The rales continued to predominate at the base, towards which situation they were more numerous, finer, and 564 PLEURISY. nearly crepitant. In the middle of the right side of the chest, towards the vertebral hollow, there were still heard the blowing sound, rales, and ampho- ric voice. The expectoration remained mucous and scanty : in the twenty- four hours, she only filled a fourth part of her spittoon. Death, which had been foreseen, in consequence of the rapid wasting of the body and the intensity of the fever, occurred on the 22d June, exactly a month from the date of the patient's admission to our wards. At the autopsy, there was found general tubercular peritonitis, and ulcerations of the intestine, which explained the persistent diarrhoea. During life, the existence if these lesions was not indicated by any pain in the abdomen. There was very little fluid found in the right pleural sac, although the thoracic pleura was injected with blood and studded with crude tubercle. There were no pulmonary adhesions. The two inferior thirds of the right lung were transformed into an almost compact mass. In the vertebral hollow, the situation in which the amphoric sounds had been heard, there was a tubercular mass, the size of a small orange, presenting the aspect and consistence of mastic. In its most superficial part, there was hollowed out a cavern the size of a small filbert-nut, separated from the surface of the lung by a partition which at most did not exceed two millimetres in thick- ness : in the neighborhood of the cavity now described, there were five or six smaller ones in course of formation. A tolerably large cavity and three smaller ones were found at the base of the lung, which was bound to the diaphragm by close and almost cartilaginous adhesions. The summit of the lung was supple and crepitant. When cut into, the section showed tubercular granulations, which at certain points were joined together in twos or threes. Around the tubercular masses, the pulmonary tissue seemed healthy and perfectly permeable to air. At the middle of the upper lobe of the left lung, there was found a cavity large enough to contain a hazel-nut: around this cavity were three much smaller cavities, which accounted for the cavernous rales with metallic resonance heard during the latter days of life. Throughout this lobe, numerous crude tubercles were disseminated. We found pulmonary ob- struction, and concomitant bronchitis. The inferior lobe was everywhere pervaded by tubercles : iu its superior part, there were crude tubercles, and at the base gray granulations. The patient, though a woman in respect of development of organs, was a child when regarded from a pathological point of view. She had the tuberculization of childhood-generally disseminated and not circumscribed tuberculization-the acute and not the chronic form of the disease. Not only had she tubercles almost everywhere; but the pulmonary tuberculiza- tion exhibited that irregularity in localization which is peculiar to child- hood, that is to say, a development of the disease proceeding sometimes from the base to the summit, and not always from the summit to the base, as in the adult. The/ result was an occurrence, quite exceptional in a woman, though perfectly usual in a very young child,-the formation of cavities at the base of the lungs before tubercles had appeared in their summits. You now understand how, taking into account the rarity of cavities being produced at the base of the lungs in the adult, when none exist in their upper parts, and on the other hand, considering that pleurisy with signs of cavities, though in itself unusual, is more frequently met with than that rare form of tubercular disease, it was more rational to conclude that the young woman had pleurisy than tuberculization. Gentlemen, I have still a few words to say regarding intercostal fluctua- pleurisy: paracentesis of the chest. 565 tion, a sign which appears to me to have a certain degree of importance, because, in cases of effusion into the pleura, it confirms the information furnished by thoracic dulness. Surgeons have pointed out that fluctuation in the intercostal spaces is met with in cases in which purulent effusion has formed an exit for itself through the thoracic walls; but I am not aware that intercostal fluctuation has been described as a sign of pleural effusion. Let me explain to you how I was led to suspect, investigate, detect, and finally to produce at pleasure this'special fluctuation. In practicing percussion, I had for a long time been in the habit of employing a pleximeter and a hammer. When measuring, in my hospital patients, by striking on the pleximeter, the extent of the dulness discovered, the hypothenar region of my left hand resting on the wall of the chest, I felt that at each stroke of the hammer an impulse was conveyed to the pleximeter. With a view to ascertain whether or not the vibrations were imparted by the hammer to the chest, and transmitted by the ribs, I so placed my hand that its hypothenar region chiefly rested on an intercostal space; I thought I then felt fluctuation. Placing the palmar surface of my index finger upon an intercostal space (I percussed between different intercostal spaces) I distinctly felt fluctuation at each stroke: by making repeated experiments, I was easily able to determine the difference between the vibrations transmitted by the thoracic walls and by the fluctuation of the fluid. In thoracic vibration, there was felt under the hand the vibration of a mass, whereas on applying the palmar surface of the index finger to an intercostal space, the sensation was that of a fluctuating liquid. This fluctuation, which many of you have been able to verify along with me, is not at all a matter of doubt, when the observer proceeds in the manner I have now described. By a little practice one easily acquires the art of detecting the fluctuation. I must add that it is not easily perceived, when there is a large amount of effusion. I do not wish to attach too much importance to this sign ; but I think it is one which deserves to be men- tioned. Before speaking to you of paracentesis of the chest, an important subject which will occupy us during several meetings, I was anxious to discuss some of the new questions connected with the diagnosis of pleurisy. It will be easier for me to lay before you what I have to say upon puncturing the chest, now that I do not require to digress from my principal subject, to explain details regarding the diagnosis of effusion. Paracentesis of the Chest.- Cases.-Historical Sketch of the Operation for Effusion into the Cavity of the Pleura. In 1855, I performed paracentesis of chest in a female patient of thirty years of age, who had pleurisy with extensive effusion. The woman to whom I refer was the occupant of bed 12, St. Bernard's Ward. She had always enjoyed good health. At least, she said, and repeated many times, that she had never had illness in any degree serious, till attacked by the malady on account of which she came to the hospital. The beginning of the malady she thus described. About two months before her admission to the Hotel-Lieu, without any preceding discomfort, without exposure to cold, without appreciable cause of any kind, she was suddenly seized during the night with exceedingly violent pain in the side. Next morning, however, she went to work as usual, although there was still some pain, which was increased by the smallest exertion. The breathing was oppressed, and much shorter than 566 pleurisy: paracentesis of the chest. usual. For seven weeks, the only constitutional symptoms which showed themselves were slight general discomfort and loss of appetite; but eight days later, they had so greatly increased in severity, that she was compelled to relinquish her ordinary avocations, to keep her room, and indeed her bed, for the greater jSart of the day. She had rigors on the 2d May. On that day, her difficulty in breathing, till then not very great, became more urgent, and during the afternoon, she was admitted as a patient to the Hotel-Dieu. During the evening, she was seen by Dr. Beylard, my chef de clinique, who found her in a feverish state. He noted the following particulars. On uncovering the chest, he was at once struck with the conspicuous thoracic deformity. The left side was greatly arched ; the left was more flattened than the right subclavicular region, and during great inspiratory movements, the left side did not appear to move. On percussion, absolute dulness was detected, extending from below upwards in front, till within four or five centimetres of the clavicle, and behind, to the crest of the scapula. Above the region of dulness, both in front and behind, there was resonance. On applying the ear to the chest in that situation, bronchial blowing and bronchophony were heard. The blowing extended to the top of the scapula; and in the infraspinous fossa well-marked segophony was heard. The patient had slight cough without expectoration. There was not much fever. The diagnosis was easy. It was evidently a case of extensive pleuritic effusion, produced by one of those singular pleurisies which are accom- panied by slight general symptoms, and yet lead to very profuse serous exudation. This case, gentlemen, merits all your attention, as a proof that there is a species of pleurisy, in which, if we are to form an opinion from the general symptoms, inflammation has little to do, and in which the functional dis- turbance dependent upon the lesion of the respiratory apparatus is so insig- nificant as to escape notice. In ordinary acute pleurisy, along with fever and other decided symptoms of constitutional disturbance, there is a violent stitch in the side and great dyspnoea : but in that particular form of pleurisy of which I am now speaking, there is hardly any fever, the stitch in the side is scarcely felt, and respiration seems to go on as usual. Well, then, gentlemen, mark, that it is this species of pleurisy, to a certain extent latent, which gives rise to the most profuse effusion. The constitutional disturb- ance, I repeat, caused by the effusion is apparently so insignificant, that the individuals allow a very long time to elapse before they seek medical aid ; and consequently, the physician has only the signs furnished by ausculta- tion and percussion to guide him in his diagnosis. Our patient consulted two physicians; and one of them, to whom she ap- plied for advice for a uterine affection, did not even suspect that she had effusion into the pleura, because he saw that she had come to his house on foot, and did not make the slightest complaint of being winded from ascend- ing his stair. Clearly understand, gentlemen, that in mentioning this cir- cumstance, I do not reproach my colleague for having committed an error in diagnosis; for he certainly did not make an error: I only wish to show you how easy it is to allow an affection to pass unperceived, when it does not declare itself, and when its physical signs have to be searched out. I remember that, in 1845, a nurse came on foot, carrying her infant, from the Pointe Saint-Eustache, where she lived, to the Necker Hospital, where I was then one of the physicians on duty. She had walked that dis- tance, about four kilometres [two and a half English miles], without being pleurisy: paracentesis of the chest. 567 much tired. The effusion was nevertheless so considerable, that on the very day she came info our wards, I judged it indispensably necessary to per- form paracentesis. I withdrew 2500 grammes [two and a half litres] of fluid. This woman certainly seemed to be very little of an invalid, and so slightly did she feel out of sorts, that on the evening before the day on which she came into the hospital, she was working as usual. The absence of oppression in breathing is a very important feature for consideration in these cases: I cannot too earnestly impress on your minds what I have now described, and what you yourselves have seen in our patient of St. Bernard's Ward. Although her chest contained two litres and a half of serous effusion, her breathing seemed to be scarcely affected. Treasure this fact in your memories, for dyspnoea has been given, and in- deed formerly used to be given by myself, as the chief indication of the necessity of paracentesis. I was singularly mistaken as to its value, as I shall have occasion to tell you in the course of these lectures. To wait for the dyspnoea, as has been recommended, and as was formerly laid down by me as the rule, is to run the risk of allowing the time for operating to pass, and of letting the patient die, as I have done. It is above all things im- portant to ascertain the extent of the effusion. Upon this point, ausculta- tion and percussion furnish us with information in which we can place implicit reliance. The chest must be examined daily by these means; and when the progress of the hydrothorax is watched in this way, and is seen to be increasing very rapidly, the indication to operate is peremptory, what- ever may be the degree in which dyspnoea exists-whether there be great difficulty in breathing, or whether there be no difficulty at all. It was this consideration which constrained me to operate at my first visit without any waiting, in the case of our patient in bed 12, St. Bernard's Ward. On the evening of that day, as I have already said, Dr. Beylard had still found resonance in the infraspinous fossa, and in a space from four to five centimetres under the clavicle. Next morning, the dulness was absolute everywhere. The effusion, therefore, had made great progress within fifteen hours. It was estimated that half a litre of liquid was secreted by the pleura between morning and evening. Moreover, the displacement of organs testified to this increase. The heart was not in its natural position ; the apex was felt to beat under and near the right edge of the sternum, as was easily ascertained by the aid of the stethoscope and pleximeter. That I might eliminate every source of error, and not be influenced by the sense of sight, I percussed the patient with the eyes shut. Proceeding thus, I limited the dulness, begin- ning at the right, to three centimetres beyond the median line: the medias- tinum and heart, therefore, were considerably displaced, and pushed to the right; on percussing from above downwards, I found dulness extending from the border of the false ribs, where I discovered that the spleen was out of its normal situation, showing that the diaphragm was squeezed up. The great amount of effusion, and its rapid progress within a short space of time, convinced me that the operation was urgent, and could only be delayed at the risk of the patient dying before next day. I performed paracentesis of the chest according to the plan I have described to you, and drew off 2000 grammes (2 litres), of perfectly clear yellowish serosity. As the fluid was being evacuated, the patient experienced a measure of com- fort which was a great contrast to the feelings of distress of which she had previously been complaining. The vaulted form of the chest was gone; and with the aid of the pleximeter, I could follow the movements of the heart, and perceive that its apex was again in its proper situation near the 568 pleurisy: paracentesis of the chest. left nipple. The spleen too had retreated to its natural position under the false ribs. After the operation, which, as the woman herself stated, was not at all painful, the pulse, formerly weak and irregular, regained its power and regularity. The patient ceased to complain of a feeling of extreme weak- ness which had prevented her from sitting up through fear of syncope. All the effused fluid, however, had not been evacuated: there was still dulness as high up as the nipple, but respiration was heard in every part of the chest. At a point where a few minutes previously no sound was audi- ble, we now heard blowing, vocal resonance, and segophony. The absorption of the fluid took place gradually, and during some following days nothing noteworthy occurred. The general condition of the patient went on improving: by the 15th May, resolution of the pleurisy was complete, and recovery was sufficiently perfect to allow her to leave the hospital at her own request. However, on percussing the chest, I still found dulness, or a hardness of sound from the infraspinous fossa down to the lower part of the chest. This dulness remains a long time after the most ordinary pleurisy, being caused by the presence of false membranes, which require a certain time for absorption. On auscultation, I perceived the vesicular murmur everywhere, but it was accompanied by coarse and subcrepitant mucous rales. Gentlemen, similar cases will no doubt occasionally come under our observation: but I could not allow this opportunity to pass without speak- ing to you of paracentesis of the chest in the consecutive effusion of pleurisy; and with your permission, I propose to devote several lectures to the development of this grave and important subject. It will be granted, I trust, that I seldom speak of myself. Indeed, generally, I attach very little value to questions of priority. I am entitled therefore, once, in passing, to lay claim to as much as belongs to me, in respect of paracentesis of the chest. I make no pretension to being the originator of the practice: I have not invented an instrument for the more easy performance of the operation, nor have I recommended any operative proceeding which was not previously well known: but I conceive that, if not the first, I was at least among the first to point out in a precise manner the necessity of resorting to paracentesis in pleurisies followed by a great amount of effusion. I established with precision-perhaps with more pre- cision than had been previously attained-the indications for operating; and I believe I popularized the method which is now generally adopted, thus entitling me to be looked upon as having somewhat contributed to the progress of the therapeutics of pleurisy. Let me tell you, gentlemen, how I was led to inculcate the necessity of surgically interposing in the treatment of extensive hydrothorax. In 1832, a woman aged 50 was admitted to the Hotel-Dieu, and became a patient in these wards, of which I then had charge jointly with Dr. Recamier. For five days, she had been suffering from acute pleurisy. The breathing was exceedingly oppressed: on the left side, there was complete dulness: the heart was pushed over to the right side: the ribs were far apart. A large blister was applied to the chest: digitalis was administered: in a word, active treatment was instituted. The woman died on the day follow- ing that on which she was admitted to the hospital. At the autopsy, we found the left pleura distended by an enormous quantity of limpid serum, in which fibrinous flakes were floating. The lung was squeezed up against the vertebral column; and both the pulmonary and costal portions of the pleura were slightly coated with false membrane. We found no tubercular products, nor any other serious lesion. pleurisy: paracentesis of the chest. 569 This case was a direct contradiction to what I then believed, in common with the majority of authors, as to the small degree of danger attaching to an attack of pleurisy: more extended experience has convinced me how erroneous were the ideas entertained on that point. Other unfortunate cases observed by me and others have negatived the law laid down by Dr. Louis, adopted by his pupils, and re-echoed by numerous physicians, to the effect, that pleurisy is never an immediate cause of death-a law, be it noted, founded on a series of 150 cases of simple pleurisy which terminated in recovery. One of my pupils, Dr. Lacaze du Thiers,* has collected a number of cases, some communicated by me and others derived from different sources, which absolutely demonstrate that, notwithstanding the famous law of Louis, it is possible to die, and to die suddenly, from acute pleuritic effusion. Very recently, my friend Dr. Lasegue saw a young physician die from this cause, at the very moment that he was about to make the puncture. On 7th April, 1843, I received into bed 31 of St. Anne's Ward of the Necker Hospital a woman of 42 years of age, with paralysis of the inferior extremities, bladder, and rectum. The intellectual faculties were unim- paired. The paralysis, which did not affect the superior extremities, had set in suddenly three years previously, and had not since that time become modified. Ten days before admission, this woman was seized with stitch in the side, cough, dyspnoea, and fever. On examining the chest, I at once detected pleurisy, with effusion on the right side. Dulness extended up to just below the clavicle : segophonic resonance of the voice and bronchial blowing were audible. The cough was dry. Some relief followed a bleeding which I had ordered, but the oppression of breathing continued very urgent. Next day, the orthopnoea assumed very great intensity. The pulse became small and wretched ; and finally, death took place, without a struggle, twelve days from the beginning of the disease. I shall say nothing of the lesions of the nervous system, which were not at all of a severe character. In the right pleura, there was an enormous effusion of purely serous character: the lung, pressed against the vertebral column, was shrivelled and covered with soft false membrane, which had a reticulated appearance: some fibrinous flakes were floating in the effused serosity. The occurrence of this case of sudden death, from acute pleurisy with profuse effusion, recalled to my recollection that which I had observed eleven years previously in the wards of Dr. Recamier. It set me to think. I asked myself, whether the fatal issue might not have been prevented in both these cases by rapidly disembarrassing the chest of the fluid which it contained, and to the presence of which the untoward symptoms were due. I asked myself, whether under such circumstances paracentesis was not dis- tinctly indicated. In the same year, and at an interval of exactly a month-on 8th May, 1843-a seamstress, thirty years of age, was admitted to St. Theresa's Ward, bed 8, for pleurisy without effusion: she too was carried off in consequence of paracentesis not having been resorted to. This woman had been deliv- ered at the Maternity Hospital on the 19th of April, and had left that insti- tution, in good health, on the 27th, except that she had a slight cough, which had existed for four days. Next day, the 28th, she fell ill, in conse- quence, perhaps, of the imprudences to which these unfortunate puerperal / * Lacaze du Thiers: De la Paracentese de la Poitrine et des Epanchements Pleurgtiques qui necessitent son Emploi. \_Thise de Paris, 1851.] 570 PLEURISY: PARACENTESIS OF THE CHEST. women so frequently expose themselves. On the same day, the 28th, she had fever, slight oppression, and an increase of cough. These symptoms increased up to the 8th May, when, along with her infant, she was admitted to my ward for nursing women in the Necker Hospital. The lochial dis- charge, which had ceased for some days after the fever set in, was not long in reappearing, and at the date of admission, was flowing in a normal man- ner : the secretion of milk was scanty. On the 9th May, the twelfth day of the disease, at my visit in the morn- ing, I dictated the following report: " Oppression, without orthopnoea: countenance somewhat anxious: a dry but not frequent cough : expectora- tion frothy and scanty, and having the appearance of saliva. Complete dulness on the left side of the chest as high up as the lower margin of the clavicle: a considerable arched appearance of the chest in front: respiratory sound absent, but there can, however, be heard a distant, very feeble mur- mur, without segophony and without vocal resonance. On the right side, respiration is puerile." The heart was noted as being beyond the median line. I ordered four basins of blood [quatre palettes]* to be taken from the arm, and put her on strictly low diet, broth only being allowed. She was recommended to drink very little. Next day, there was no change in the condition of the patient. It was observed, that the blood drawn on the previous evening was very much cupped. I ordered the treatment to be continued. Between the 11th and 17th May, there was a slight amelioration, which, however, was soon succeeded by an exacerbation of the malady. There was a tendency to syncope. Two flying blisters were applied to the affected side, at the interval of a few days; and diuretics were administered. On the 17th, the state of the patient was manifestly worse. She lay on her back, without pillows, and did not seem to have any oppression: never- the less, her countenance was pale and anxious, and her eyes wide open. Her respiration was feeble and imperfect: her pulse was miserable: her in- tellectual faculties, however, were unaffected. It seemed as if she were dying, suffocated by a power against which she had ceased to struggle. The two cases which I have just related to you presented themselves to my mind: I saw that my patient was in similar peril, and paracentesis sug- gested itself. But as it was a somewhat unusual proceeding to resort to this operation at the twentieth day of a pleuritic attack, as the operation was at that time loudly condemned in acute cases of effusion by all French physicians, and indeed in all cases of hydrothorax; as the oppression of the breathing did not seem to me to be very great, I yielded to the culpable weakness of preferring to wait: in fact, I wished to avoid the imputation of rashness. I directed my interne to watch the patient, and to puncture the chest in accordance with a plan we agreed upon, should life seem in ex- treme jeopardy. My pupil saw the patient at seven in the evening, for the last time. She did not then appear to him to be in a worse state than in the morning: believing that paracentesis might be delayed, he left her for a little. Within an hour, the unfortunate woman died without a struggle. At the autopsy we found that the heart was pushed quite to the right side, and that the left pleura was distended by an enormous quantity of fluid, which we estimated at not less than four litres. This serosity was limpid in the upper part of the chest, but in the depending parts it was seropurulent: the lung was shrivelled, and was squeezed up against the vertebral column. At the summit it was closely adherent to the costal * A "palette" is a basin used for receiving blood taken by venesection. It con- tains 75 grammes, i. e., 8J fl. ounces.-Translator. PLEURISY: PARACENTESIS OF THE CHEST. 571 pleura, and at that point there was a cicatrix consequent upon softened tubercle. In no other situation did we find any appreciable organic altera- tion. I was, as you may suppose, shocked by the death of this woman; and, too late for her, I perceived the necessity of having recourse to paracentesis at the earliest possible opportunity in similar cases. I had not long to wait for an occasion to give practical effect to this conviction. In the following September I went to Tours to see my mother, who was dangerously ill. During my absence I had been sent for by my excellent friend, M. Michel Masson, the dramatic author, with whose name you are familiar, to see his daughter. She was a young lady of sixteen, who gen- erally enjoyed good health, excepting that she had great nervous irritability. During the ten years that I had been the family physician I had hardly once been consulted regarding her. On Sunday, September 3d, 1843, she had fever and loss of appetite. On the 5th she took to her bed. I did not see her till the 8th. I then observed that the skin was very pale, and that there was considerable fever: she had a little dyspnoea, but neither cough nor expectoration: there was no symp- toms of any gastric affection. On exploring the chest I found that there was enormous effusion in the left pleura, ascending as high as the clavicle. Everywhere complete dulness existed; and in no situation could I hear the respiratory murmur, blowing, or segophony. The heart was twisted to the right, and occupied the median line. I bled her from the arm, prescribed calomel, and recommended her to drink sparingly. On Monday, September 11th, the eighth day of the attack, there was a great increase in the severity of the symptoms. The skin was cold, and the face pale. On account of the orthopnoea, the young lady was obliged to sit up in bed supported by pillows. She had a tendency to syncope, and groaned without ceasing, f applied a large blister to the posterior aspect of the chest. I resolved to perform paracentesis; and as the indication to operate was urgent, I did not wish to have a consultation, fearing, on the one hand, that a meeting of doctors upon her case might alarm the patient; and, on the other, that the conflict of opinions, certain to arise, might lead the family to fatal indecision. Consequently, when I arrived on the Tuesday morning -the ninth day of the illness-I was provided with the necessary instru- ments, and perfectly determined to fulfil the commands of duty, without making the slightest parade, just as if I were about to do the simplest thing imaginable. I found the patient at the brink of death, and reproached myself for having on the previous evening postponed a proceeding which had become so peremptory as to admit of no delay whatever. I performed the operation in a way which I shall point out to you when I come to speak of the manual operation of paracentesis, which is a very simple affair. I withdrew about 800 grammes [between one and two pints] of transparent serosity, having a beautiful amber color. It retained its transparency till next day, but there was visible in it a sort of soft, shreddy tissue, evidently formed of fibrin condensed by the cold. Although I could easily have withdrawn a larger quantity of the fluid, I did not wish to do so, being satisfied with having removed the excess which rendered the effu- sion mortal, so reducing the case to simple pleurisy, curable by ordinary means. When the operation was completed, the young lady seemed to return to life: she breathed easily, had no longer an anxious countenance, and her pulse had regained some degree of volume. The lungs and heart had re- turned to nearly their normal position: the respiratory murmur was once 572 PLEURISY: PARACENTESIS OF THE CHEST. more audible: there was a little tympanic resonance in front, at the upper part of the chest, which, at the time, I thought was attributable to the entrance of some bubbles of air during the operation. I was not then acquainted with the exaggerated resonance observable in the majority of pleuritic cases-that peculiar resonance which, at a later date, Skoda dis- covered and made known. During the night which followed the operation, the patient slept six hours. Next morning, she was in a very nervous state, but respiration was easy: she spoke fluently, and made use of long phrases without taking breath. Her countenance was calm. The skin was rather hot, and the pulse 112. On the second night after the operation, she slept eleven hours. There was a notable diminution in the quantity of effusion in the chest: the heart was more and more resuming its place on the left, although it was still beyond the median line. Anteriorly, the dulness did not rise higher than the fourth rib. The subsequent history, I shall rapidly sum up. Under the influence of flying blisters applied to the chest, diuretic drinks, and digitalis, improve- ment went on rapidly. On 28th September, sixteen days after the opera- tion, the pulse was 80 : she had a decided relish for her food : the menstrual flux came at its proper time, but not in normal abundance. From that time, all the morbid symptoms disappeared: respiration became natural, and the patient entered upon a convalescence which had a favorable issue. This case taught me a great lesson. It prevented me from having any hesitation in acting in the same way under similar circumstances. Having had three similar cases of success, I hastened to publish them. They formed the subject of a memoir which was read to the Academy of Medicine in 1843: during the following year, I communicated a second memoir to the Academy on the same subject.* In 1846, the duty of reporting on these two memoirs was intrusted to my honorable colleague Dr. Bricheteau, in whose presence I performed paracentesis of the chest upon a girl of fourteen years of age, who made a rapid recovery. In the report of this excellent practitioner, which is a real masterpiece of erudition and criticism, the con- clusions drawn by me are adopted with very slight modifications. The report hardly gave rise to any objections, so that the discussion upon it attracted no attention. I now more than ever followed out my views in this matter: successes were multiplying, and encouraging me to pursue the same course, when, in 1850, having asked my colleagues of the Medical Society of the Hospitals to give me their opinion upon a case of death following paracentesis of the chest, and information upon a peculiarity in the case, I was led to explain my views on the general question of paracentesis. The controversy was animated; and I found myself confronted by as violent an opposition as that which I encountered when I published my first cases of tracheotomy. Ill-natured insinuations were not wanting upon that occasion. When I brought forward cases of children cured by tracheotomy, I was told that they had never had croup; that only those children had had croup whom I had failed to save: I was even caluminated. According to my custom, I made no reply. Influenced only by an approving conscience, I continued to pursue the practice, hoping that truth would, sooner or later, carry the day. In respect of tracheotomy, I attained my object; for that operation has for a long time been generally acknowledged as indicated in the cir- cumstances in which I declared it to be necessary. Paracentesis of the chest was not met by the same objections, but, nevertheless, encountered * Bulletin de 1'Academie de Medecine, t. ix, p. 138 ; Ibid., t. x, p. 517. pleurisy: paracentesis of the chest. 573 many opponents. When, however, it became known that I had operated in from fifteen to twenty cases, in two instances among others upon Parisian physicians, without having had one failure to deplore ; when many of my fellow-practitioners in the hospitals and in the town (my youthful col- leagues be it observed, for the elders hardly like to follow the example of juniors), when, I say, many of my colleagues had also operated successfully, paracentesis was proclaimed as a good means of treating acute pleurisies accompanied by profuse effusion, just as tracheotomy had ultimately been accepted in the treatment of croup. Far be it from me, gentlemen, to appropriate to myself the honor of the discovery. Paracentesis of the chest has been practiced from very remote times; but, exposed to varying fortunes like every other therapeutic measure, it was all but abandoned, or at least was reserved for exceptional cases. It was resorted to distrustfully, and then only when imminent peril justified extreme daring. If it have now taken that place which it ought always to maintain, if it be now mentioned among modes of treatment which have the advantage of being free from danger, I conceive that I have contributed to bring about this change of opinion by my works, by the indications for operating which I have furnished, and in a special manner, let me add, by the success which has attended my practice. Before I point out to you the circumstances in which this method of sur- gical interference is indicated, allow me briefly to recapitulate the history of paracentesis of the chest, following it in succession through its different phases. I cannot explain to you in any other way why an operation, never before adopted as an ordinary practice, is at present performed in all places, and by all practitioners. The earliest data relating to puncture of the chest are as old as the school of Hippocrates. The operative procedure indicated in his times is followed in the present day. There are two modes of operating: we either open into one of the intercostal spaces, or we perforate a rib. The intercostal space may be opened by actual cautery or bistoury. Whatever method is selected, it is essential that the wound remain open till the fluid is entirely evacuated, and till there is no tendency to more effusion. If the opening should have a tendency to close, this must be prevented by the introduction of a metallic sound. Such is the operative basis upon which surgeons have proceeded since the time of Hippocrates ; and it is not uninteresting to see how little they have added to the old traditions. Galen simply repeated the rules laid down by Hippocrates: Celsus did not describe the operation very happily; and paracentesis, almost forgotten by the writer who for so long a period was the sole authority on the subject, fell into discredit among the Greeks and Romans, and was not revived by the Arabs. During the middle ages, it was discussed, whether it were better to make the opening into the chest by steel or fire ; but it was scarcely admitted that there was any cases except those of surgical lesions in which paracentesis ought to be performed. About the sixteenth century, trepanning the ribs was revived, after having been almost abandoned. About the same time, detersive injections, which had been recommended by Galen and Rhases, were again advocated as a necessary element in the treatment. We find, however, that in those times, the operation was seldom tried, and that, even in extreme cases, it was gen- erally rejected by the greatest surgeons. Fabricius of Acquapendente, for example, regretted that it had fallen into desuetude. A more attentive study of facts, however, and a less servile obedience to tradition, led to some important observations. 574 pleurisy: paracentesis of the chest. It was remarked that in penetrating wounds of the chest, recovery seemed to take place most quickly, when the wound was closed early; and it was then asked, whether it would not be expedient to close the opening made in paracentesis for empyema, in place of leaving it patent for an indefinite period. From the seventeenth to the eighteenth century, the operation of paracen- tesis was the topic of numerous surgical treatises. In 1658, Bontius for the first time took up in a precise manner the subject of the introduction of air into the chest, which till then had been hinted at, rather than discussed. He declared that there was nothing to dread in the contact of air, and con- sidered injections as a perfectly sufficient means of combating the conse- quences which were dreaded. Bartholin maintained the opposite opinion : he insisted that the opening ought to be closed with the least possible delay, to prevent at all hazards contact with the air. The indication for the operation was then laid down ; but two centuries elapsed before a satisfac- tory manner of fulfilling it was attained. The more that attention was directed to the question of the admission of air, the more was the manner of operating modified. The fluid was evacu- ated by aspiration and suction: this practice was at first very timidly pur- sued, in accordance with Scultet's example; but it became afterwards in vogue with the masters of surgical art. Surgeons had now entered upon a new and very propitious path. In place of discussing theoretical probabilities, they proceeded to direct exami- nation of facts. As cases of paracentesis were still of rare occurrence, they based their observations on examination of wounds of the chest. They thus, from considering the small number of untoward occurrences which such accidents lead to, became less distrustful of puncturing the chest, and were even led to believe in the harmlessness of the operation. As a consequence of this tendency, felt rather than expressed, physicians began to study the question of puncturing the chest in hydrothorax. In 1624, Gerome Goulu alleged that he succeeded more frequently in hydro- thorax than in abdominal paracentesis in ascites. Twenty years later, we read in the writings of Zacutus Lusitanus that paracentesis was as much indicated in cases of serous effusion into the chest as in cases of empyema, if puncture was the only means of evacuating the fluid. Some time after- wards, this practice was put in force by Willis; Lower also mentions a case; and subsequent authors quoted these cases as an encouragement to the performance of paracentesis of the chest for the removal of serous effu- sion. About the middle of the eighteenth century, when perforation by the actual cautery, which till then had its partisans, was abandoned, it was proposed to substitute for the bistoury, a trocar such as was employed in abdominal paracentesis. In 1765, Lurde recommended the use of this in- strument, which, however, had been proposed nearly a century before by Drouin. Lurde's recommendation was timidly given, through the fear which he had, that in using the trocar there was a risk of wounding the lung. He advised the operator to close the canula with the finger at each inspiration, leaving it open during expiration, so that the entrance of air might be prevented. Lurde's recommendation to employ the trocar was not so well received as might be supposed ; and among its adversaries were Chopart and Desault. The use of the trocar was alleged to be a coarse mode of proceeding, and to involve the risk of wounding the intercostal artery and the lung. More than a hundred years elapsed before the sug- gestion of Drouin found support; and we can still see with what difficulty it obtained adherents, notwithstanding the future which was in store for it. pleurisy: paracentesis of the chest. 575 Finally, in 1808, Audouard raised anew a question, considered as defi- nitely settled, attacking a universally admitted conclusion. From the time that paracentesis was first practiced, the rule laid down was to allow the fluid to flow only little by little. On the first day, a portion was drawn off; on each succeeding day, the evacuation of a small additional quantity was promoted. This precept originated in the conviction, that if the fluid escaped suddenly, the result would be a vacuum in the chest causing the death of the patient. This hypothesis, afterwards admitted to be unsatis- factory, was replaced by another explanation; but the rule remained. Audouard maintained and proved that even the sudden evacuation of the fluid is not attended by the drawbacks which had been supposed to exist. Between 1808 and 1843, when I published my first work on the subject, the manner of performing the operation had scarcely undergone any modi- fications, suggested changes not having been sanctioned by experience. Certain facts, however, had been ascertained : it had been found that the fluid might be evacuated rapidly, and at one time; also, that while it was incumbent on the operator to prevent as much as possible the entrance of air, there need not be much alarm as to the deleterious consequences of such an occurrence. The soundness of these two principles being admitted, it followed that the trocar was considered preferable to the bistoury; that perforation of the ribs ceased to be practiced ; and that various plugs were invented as substitutes for the finger, which Lurde recommended to be placed at the external orifice of the canula. Every apparatus constructed for adaptation to the trocar, with the view of preventing the introduction of air and leaving free passage to the fluid, was made on the principle announced almost simultaneously by Schuh and Reybarb, but which has been especially elucidated by the former. The apparatus of Schuh, a complex machine composed of a system of plugs and reservoirs difficult to work, has been abandoned by its inventor. The simplicity of the trocar devised by Reybarb has led to its adoption by all operators. Its peculiarity consists, as you know, gentlemen, in arming the free extremity of the canula with a piece of goldbeater's skin, which, being rolled round the instrument, is then softened by water. The gold- beater's skin thus adjusted, acts as £ plug, and has the advantage over every other mechanical contrivance of requiring neither precision nor re- pairs.* In summing up what has been said regarding the operative proceeding itself, you perceive that a certain number of desiderata have been pointed out; and that all of them have now been so well supplied, that there is not much scope for future improvement. You perceive from what has been said, that even at the time when paracentesis of the chest was performed under conditions and with instruments far from favorable, it took its place among the least delicate operations of surgery. Nevertheless, puncturing the chest continued to be looked upon as one of those bold measures only sanctioned by the existence of danger of a cer- tain urgency. The cause of this timidity arose from insufficient knowledge of the indications for operating, and not from any imperfection in the mode of performing the operation. It is impossible for any therapeutical means to be regarded with general favor, be it a medicine or a surgical operation, unless it be suited to a de- terminate exigency. A remedy will remain unemployed, so long as the circumstances which demand its employment are imperfectly known. Or at most, an experimentalist tries it at a time, in a sort of haphazard way, * Gaujot : Arsenal de la Chirurgie Contemporaine. Paris, 1867. 576 pleurisy: paracentesis of the chest. and announces a successful result: others, who attempt to follow in the same direction, either use the remedy too timidly or too indiscriminately, thus discrediting it, and causing it to fall into oblivion. Such has been the fate of paracentesis of the chest. It is not surprising that De Haen should have asked in reference to hydrothorax : " Cur ita laudata paracen- tesis sive ut primum sive saltern ut alterum adhibendum auxilium spatio XXIII seculorum theoretice commendetur et vix unquam instituta legatur?" I have now rapidly sketched the history of the operation; but to make this history practically instructive to you, I must state the indications for resorting to paracentesis. When Hippocrates recommended tapping of the chest, he distinctly in- dicated the intention of the operation--the evacuation of fluid contained in the thoracic cavity; but he did not furnish signs sufficiently precise to enable effusion to be detected during life. His description of symptoms is applicable to affections of very different kinds; it comprises, along with dropsy of the chest, hemorrhagic and purulent effusions, and in particular hydro-pneumothorax. Thus, the beautiful experiment of succussion, which still holds its place among the most valuable physical signs, is given as an absolute criterion. It had been perceived that the local phenomena were deficient in precision, and by way of supplementing them, a number of general phenomena, still more deceptive, were added. It is curious to see, that at the commencement of the nineteenth century, the diagnosis of effu- sion into the pleura had not gained anything in respect of exactitude. The Hippocratic description, invariably reproduced by all succeeding authors, is repeated by Mursinna, who, however, iu 1811, had operated four times, and twice successfully, guided only by these untrustworthy data. In his re- markable dissertation, the German surgeon insisted that the sound caused by succussion was an indispensable element in the diagnosis. He speaks of oedema of the inferior extremities and scrotum as a symptom almost in- variably present; and adds, without making more direct reference to the discovery of his fellow-countryman Avenbriigger, a statement to the effect, that a dull sound of a very peculiar character is sometimes heard on per- cussion. No one has shown more clearly than De Haen, the inadequacy of the diagnostics. His monograph orf hydrothorax is in fact an elaborate criticism upon the phenomena which his predecessors had indicated as characteristic : " Suspicio morbi duntaxat est eaque cum aliorum morbis signis ita intricata, ut certi quid concludi nequeat." He elsewhere insists upon the deceptions which beset physicians: " Sub dolus hie morbus raro dumeurabilis est cognoscitur." The result of this diagnostic uncertainty, which was felt and proclaimed by all good observers, was the restriction of paracentesis of the chest to cases extremely limited in number, and belonging to the domain of surgery. It was thought necessary to wait till the chest was enormously distended, till an intercostal space was visibly elevated by the tension caused by the pus seeking to make an exit for itself; and, generally speaking, the rule was to operate only in traumatic cases. Nevertheless, in spite of so many reasons for abstaining from operating, and though there was very little actual experience to appeal to, there was not wanting on the part of physicians belief in favorable results, and the hope of success. They asked themselves the reason for delaying the opera- tion to so advanced a stage of the case: they were convinced by reasoning rather than by facts-but they were convinced. This remark is applicable to more than one writer. So far back as 1624, Goulu, as I have already stated, alleged that paracentesis of the chest in hydrothorax was more fre- quently successful than paracentesis of the abdomen in ascites : " Ergo pleurisy: paracentesis of the chest. 577 in thoracis quam in abdominis hydrope, paracentesis tutior." Such is the con- clusion of his dissertation. In 1774, Majault took up the same thesis, and thus summed up his views: "Ergo hydropi pectoris paracentesis." De Haen, too, had said: " Ut si hydrops pectoris cognoscatur mature, nil est paracentesi tutius." The great discovery of Laennec changed the aspect of the question : in the room of confused and inextricable symptoms, auscultation substituted the simple and positive elements of diagnosis. Effusions into the chest were henceforth considered to be among the diseases which were most acces- sible to the investigation of the physician. From that moment-the ob- scurity being apparently dispelled-the desire so often expressed of extend- ing the practice of paracentesis of the chest seemed about to be realized. It, however, happened otherwise. Laennec, with his usual sagacity, had defined all the indications of the operation. He recommended its perform- ance in cases of acute pleurisy with effusion, in which the effusion, from the first very profuse, increases so rapidly, that at the end of some days it produces a general or local condition of great seriousness, possibly threat- ening suffocation, and constituting whas has received the name of acute empyema. He also recommended it as a last resource in chronic pleurisy, when every means had failed to promote absorption of the fluid ; but he added : " The operation for empyema is seldom successful." That depends on several causes, all of which have not been equally well appreciated. With the exception of particular conditions of organs contraindicating paracentesis, the condition which Laennec considered as most opposed to success was flattening and loss of elasticity of the lung, from its being covered by false membrane. Hence, he thought that there is a better chance of success in acute than in chronic empyema. The usual mode of operating did not appear to him to be susceptible of much improvement; and though he dwelt upon the danger resulting from the introduction of air, he does not seem to have inquired into the means of preventing this occurrence. " Puncture with the trocar," says Laennec, " in an intercostal space, was several times tried ; Morand among others had recourse to it several times. My friend Professor Recamier employed it several times, making use of a very small trocar. I have myself often had recourse to it, but have never obtained by it permanent success." Three pages farther on, Laennec expresses the conviction that " the operation for empyema will become much more common and much more useful, in proportion to the diffusion of the employment of mediate auscultation." As you perceive, gentlemen, Laennec does not by any means enunciate his opinion in a decided manner : he raises with one hand that which he pulls down with the other. While he promises fortunate results from the diagnostic means with which he endowed science, he speaks doubtingly of the successful results of paracentesis. He only cites unsuccessful cases, and lays stress on the anatomical conditions, only that he may bring out into stronger relief those which appeared to him to be the most unfavorable. Distrust, though tempered by the expression of better hopes for the future, was too distinctly shown by Laennec to encourage new attempts. What was the consequence? When ten years later, in 1835, the question of para- centesis was brought before the Academy of Medicine, upon the occasion of Dr. Faure's memoir being read, the discussion was confused and misty, opinions of a contradictory character being stated : on all sides, proofs were wanting : and prolonged debates terminated without any conclusion being arrived at.* * Bulletin de 1'Academie de Medecine, 1838, t. i, p. 62. vol. i.-37 578 pleurisy: paracentesis of the chest. There was a disposition to follow the authority of Laennec in France, the country in which auscultation was discovered, and an inclination to dispute the efficacy of paracentesis in the different forms of effusion into the chest which physicians are called upon to treat; and surgeons continued to employ it only in traumatic effusion. But in foreign countries, the new means of diagnosis excited better hopes from the operation. In 1834, Becker published, at Berlin, a monograph on chronic pleurisy, in which, after having explained how the progress of thoracic examination had enabled the operation to be better applied, he detailed five cases of chronic pleurisy in which paracentesis was performed at the request of Dief- fenbach ; and upon his title-page, he placed these words " Melius est anceps remedium quarn nullum.'" In 1835, Thomas Davies set himself after a some- what awkward fashion to refute the opinion of Laennec, whom he repre- sented as utterly denying the utility of the operation. In opposition to the opinion of the French physician, he declared that paracentesis is useless in pneumothorax, but that it renders very marked benefits in cases of hydro- thorax and empyema, particularly in children. His plan was to make the puncture in the intercostal space with a small trocar, without using any accessory apparatus to prevent the entrance of air. He recommended- and the recommendation has been long followed in England-that the operation should be preceded by an exploratory puncture with a needle, to ascertain the nature of the effused fluid and its degree of consistence, as well as other points, such as the presence or absence of false membranes. The support given by Thomas Davies to an operation then so little in favor was not without a good effect. His opinion was ignored in France, but had many advocates in his own country, where Davies became an authority'with all who made new trials of the operation : the feeling in its favor, however, was not a general conviction. While some performed the operation, and lauded its results, there were others who abstained from having recourse to it, and were not remiss in arguing against it. Stokes,* and afterwards Watson, insisted upon the evils resulting from paracentesis, which they alleged converted a serous into a suppurative inflammation- a false doctrine, which has been recently revived. Holding these views, they maintained that the operation ought not to be performed, unless the life of the patient was in imminent peril. In Germany, however, confidence was sustained. Schuh of Vienna gave in his adhesion to the doctrines of Becker. In 1839, Schuh, in his " Dis- sertation on the Influence which Auscultation and Percussion are entitled to exercise on Practical Surgery," declares that paracentesis is a radical cure in cases of chronic thoracic effusion, whether the effusion has or has not followed an acute attack. In that work, he lays down the principles which three years later he applied in practice. Such, gentlemen, was the state of the controversy upon this question in therapeutics, when I contributed my own researches to its elucidation. Contradictory opinions were maintained with equal keenness on both sides. Dr. Bey bard had already published an account of his ingenious instru- ment but being more occupied with the mode of operating, than with the indications for operating, he added nothing to what had already been taught on the subject. He admits that he had had few opportunities of per- sonally applying his method in practice, and from want of cases to appeal * Stokes: Diseases of the Chest: Dublin. f Reybakd : Memoire sur Les Epanchements dans la Poitrine, et sur un Nouveau. Procede Operatoire pour retirer les fluides epanches sans laisser, penetrer 1'air ex- terieur dans le thorax. \Grazette Medicale, for January, 1841.] pleurisy: paracentesis of the chest. 579 to, he supposed that dropsical effusions into the chest, generally caused by an inflammation of the pleura, ought to be cured by a single tapping. The remainder of his exceedingly interesting dissertation is specially devoted to wounds of the chest. Towards the end of 1841, two professors of the Vienna School of Medicine, Schuh* and Skoda published an important work on this therapeutical subject. As I formerly mentioned, Schuh had already, on theoretical grounds, lauded the good effects of paracentesis of the chest. Their mono- graph, which has become a classical work in Germany, deserves to occupy a distinguished place in the history of paracentesis of the chest. They begin by laying down the principle that recovery from pleurisy generally takes place when the effusion is not excessive in quantity, and when the case is without complications. Even when the effusion is profuse, they say that nature will, when aided by known means, accomplish a cure; but that the time required will extend to pionths, or it may be to years. The evils which follow pleurisy are deformity of the chest, ansemia and its worst con- sequences, viz., syncope, sudden death, formation of tubercle, and hyper- trophy with dilatation of the right side of the heart. If the effusion be to the extent of several pounds, and the fever have ceased, paracentesis is indicated, provided there has been no amelioration of symptoms for three weeks: the operation will prove either a radical cure or a palliative. Both authors set themselves to refute the arguments adduced against paracentesis, and to explain in detail the different stages of the operation. They recommended that the whole of the fluid should not be withdrawn at once, being afraid that the sudden expansion of the lung, and replacement of organs pushed out of place by the effusion, might be productive of in- jurious consequences. This fear is chimerical, as I shall show you. The work of Schuh, though supported by the authority of Skoda, did not, even in Germany, meet with the approbation which it deserved. In foreign countries, it remained unknown; and I have not once seen it quoted by French or English experimenters. Almost about the same time, just as if, in the history of this operation, it was fated that every hope of success should be counterbalanced and con- tradicted, Hope dictated his "Notes on the Treatment of Chronic Pleurisy," which were published in the Medico-Chirurgical Review (of London), in 1841. He therein endeavored to prove that pleuritic effusions did not require the aid of surgery, and that the resources of the materia medica were always sufficient for their treatment. Concurring with the physicians who, upon the occasion of the discussion before the Academy of Medicine, maintained that pleurisy is never fatal, concurring also with Stokes and Watson, Hope declared that the want of success in the treatment arose from the timidity with which the remedies were administered. He spoke very strongly in favor of the plan of pushing resolutely mercurial medicines, and giving a sustaining diet embracing animal food, even when there existed fever; and he recommended certain diuretics. He details thirty-three cases of chronic pleurisy cured by this plan of treatment. The discussions excited by these writings were not very numerous, and were soon forgotten. Attention was not fixed upon the indications, upon the advantages or danger of paracentesis; and what appeared at that date in the medical periodicals was only an occasional report of cases in which the operation was performed, both the nature of the cases and the results being very various. * Schuh: Medicinische Jahrbucher der k. k. Oesterreich. Staates. Wien, 1841. 580 PLEURISY: PARACENTESIS OF THE CHEST. In 1844, my memoir, read before the Academy, by awakening a fresh interest in the subject, called forth new researches. In England, a similar impulse was given to inquiry. It now began to be felt, that there was a sufficiently solid basis for inquiry, and that consequently, leaving aside hypothesis, facts might be appealed to. In this spirit were conceived two monographs, which close the list of English publications of any importance upon tapping the chest. I refer to the work of Hamilton Roe " On Para- centesis of the Chest in Empyema and Inflammatory Hydrothorax,"* and to the writings of Hughes, f Roe laid down excellent precepts, and con- sidered the results of experience as very satisfactory. He was not afraid of syncope, which according to the views of objectors, threatened the life of the patient immediately after the operation; nor was he afraid of the en- trance of air, against which he took no manner of precaution. The mode of operating which he recommended was exceedingly simple: he reduced the operation to a mere puncture in an intercostal space with a trocar of medium size. Perhaps, gentlemen, you may have thought that, considering the nature of the instruction which it is my duty to give, I have gone too minutely into this historical sketch of paracentesis of the chest; I wished to go fully into the matter, because I desired to show how this operation, though recog- nized in the very infancy of medicine, had had difficulty in establishing itself in the domain of therapeutics, and that its doing so at last was in consequence of the indications having been established in that precise form in which they now exist. I propose in my next lecture to go into the essentially practical parts of the subject. Circumstances which render Paracentesis of the Chest necessary.-Pleurisy may be fatal.-Profuse Effusion may cause Sudden Death.-It may occa- sion Death by Asphyxia.- On the other hand, Paracentesis may accom- plish an Immediate Cure: when this takes place, the Temperature of the Body at once becomes normal.-The Continuance of the Effusion in the Chest may occasion Hectic Fever.-The Effusion may become Purulent.- Traumatic Pleurisy.-Pleurisy may occasion development of the Tubercular Diathesis.-Latent Pleurisy is a frequent manifestation of this Diathesis, whether the Effusion remain Serous, or become Purulent, as usually occurs. -Paracentesis is also useful when there exists Hydropneumothorax.- Cancerous Pleurisy. Gentlemen: To justify paracentesis of the chest in pleurisy with a great amount of effusion, it is first of all essential to establish, in opposition to the opinion of Dr. Louis, that pleurisy sometimes terminates in death. The disease may prove fatal from the immediate effect of excessive effusion. Death may also be, in an indirect manner, the result of pleurisy becom- ing the starting-point of affections under which individuals sink sooner or later. For example, the mere continued existence of effusion, whether the fluid in the cavity of the pleura remain serous or degenerate into pus, will * Hamilton Roe : Transactions of the Medical and Chirurgical Society of Lon- don : 1844. f Hughes: Guy's Hospital Reports, 1844: and London Medical Gazette, 1846. pleurisy: paracentesis of THE CHEST. 581 cause continued fever, hectic fever, by which the patients will become ex- hausted. Let me add, that from the special nature of the inflammation which gives rise to the effusion, the effusion is often purulent from the very first. Moreover, a persistent determination towards the thoracic viscera is cal- culated to lead to the development of the tubercular diathesis in predisposed persons. Finally, the longer a pleurisy continues, the less curable is it, as the lung contracts adhesions in protracted cases which permanently prevent it resum- ing its place in the thoracic cavity, and discharging its functions. Let me pass before you in review the different propositions, now generally admitted to be true; and to which general recognition, I have perhaps con- tributed. Pleurisy may prove fatal from the quantity of the effusion being very great. This is a point which I have already established in my last lecture. I established it, not only by appealing to cases which had come under my own personal observation, but also by referring to others wrhich had been observed by physicians altogether reliable, among whom I may mention Chomel, Bricheteau, and my friend Dr. Pidoux. Among other additional examples which I could lay before you, let me present to you the following history, all the details of which I have care- fully collected. On 17th August, 1847, I was requested to see, in consultation, a man aged 44, who had been ill for six weeks. Up to the date of his attack, he had always had good health. On 3d July, he was seized with symptoms of inflammatory fever, the result of a chill, commonly called a coup defroid. He continued to walk daily from his residence at the Barriere Blanche to the War Office in the Rue Saint-Dominique, where he was a clerk. In the evening, on returning from his office, he always complained of fatigue, then of a feeling of oppression, which increased day by day, and which he com- pared to a military stock [hausse-col] painfully compressing the upper part of the chest. On 26th July, he was obliged to give in. The dyspnoea, the feeling of constraint of the chest, and the general debility went on increas- ing: consequently, he took to his bed, and sent for his medical attendant. At that time, he was coughing a little. The physician who was called in informed me that he found him in a feverish state, with rusty sputa, but without dulness of the chest on percussion. He was bled: but as the bleeding was followed by syncope, the physician was afraid to repeat it. A plan of treatment was then commenced intended to produce revulsion from the lungs to the skin and intestinal canal; while, at the same time, there were administered opiated potions to subdue the cough. It was not till the eighth or tenth day of the attack, that incipient dulness was detected on the left side: the dulness existed throughout the entire left side of the chest, both before and behind. The treatment was then changed to blister- ing the chest, and administering diuretics. The severity of the symptoms increased: the debility and the fever became more menacing. There was delirium during the night, and profuse sweating which weakened the patient: but the oppression of the breathing was only marked in a moder- ate degree. As, however, matters were going on from bad to worse, they did me the honor to call me in. The following is an account of the state in which I found the patient. The pulse was 100, soft, and easily compressed: there was sweating, which was constant, passive, and warm: the skin was rather hot: the face was flushed, the eye expressionless, and the brain " empty," to use a vulgar phrase. There was no cough, and the respirations were 25 in a minute. 582 PLEURISY: PARACENTESIS OF THE CHEST. The patient was lying in the horizontal position: on my arrival, he sat up in bed, and made no complaint, except that he suffered from fever, and wasting sweats, to use his own expression [des sueurs qui le minent]. He only made one request, which was, that the fever might be cut short: he made no mention of oppressed breathing, cough, or stitch in the side. . He passed his urine and stools involuntarily. His countenance and appearance suggested the idea of a person suffering from typhoid fever, but with this difference, that the mucous membrane of the mouth was in a normal state. On examining the chest, I found complete dulness on the left side from summit to base, in front and behind, extending to the subclavicular and infraspinous fossae: everywhere, auscultation revealed the absence of all sounds, vocal or respiratory, normal or morbid. On this side, the thoracic walls did not vibrate under the hand when the patient spoke. On the right, there existed normal resonance and supplementary respiration. There was no enlargement of the intercostal spaces, and the chest did not seem to be distended on the affected side. The effusion extended laterally to the middle of the sternum: exactly at this point, and not in its natural position, the pulsation of the heart was felt. Looking to the great amount of the effusion, and notwithstanding the slightness of the dyspnoea, I was of opinion that any attempt to promote absorption would be useless and even injurious, inasmuch as it would delay the tapping, the only efficacious treatment which could be employed. However, to enable the patient to wait till the following day (it was then three in the afternoon), I prescribed (in place of the strict low diet on which he had been placed) two cups of milk and meat broth, a slightly stimulat- ing potion, and thirty centigrammes of the sulphate of quinine. But at eight o'clock next morning, the patient died, after some hours of dreadful agony, repeated faintings, delirium, but no great amount of dyspnoea. After death, percussion of the chest gave results similar to those of the previous evening. These unfortunate cases, more of which might be cited, speak too plainly to allow any one to deny that simple pleuritic effusion, may from mere quantity, cause death. We shall afterwards see how this occurs. Enormous effusion may arise from simple acute pleurisy; and I do not believe that as yet any clinical observer has discovered signs by which to determine whether an attack of pleurisy is or is not to be followed by extensive effusion. There can, however, be no doubt that Dr. Pidoux made a correct remark when he said, that " very profuse effusion generally supervenes in a peculiar form of pleurisy, quite different from ordinary pleurisy."* It is usual to distinguish two stages in pleurisy. The first is peculiarly the inflammatory stage, characterized by anatomical changes described in your text-books, and during the progress of which occur in a marked man- ner the ordinary phenomena of inflammatory fever, with the violent stitch in the side, and the dry pleuritic cough. This stage is of short duration : and some, indeed-among whom is Laennec-have denied that it is at all distinct from the second. The second is the stage of effusion: in it the in- flammatory element appears to be relatively feebler, but continues during a period to which it is difficult to assign the limits; and afterwards the effused products undergo transformations, and originate false membranes. As an exception to the general rule, the inflammatory element is some- times very slightly marked-if we judge by the mildness of the local and general symptoms-though the amount of the effusion is considerable. * Pidoux: Memoire sur le Prognostic de la Pleurisie Latente, &c. Paris, 1850. pleurisy: paracentesis of the chest. 583 This is not peculiar to the pleura, being likewise observed in other serous membranes. Observe what takes place in the synovial membranes. In certain forms of articular rheumatism the phlegmasia, characterized by intensity of local pain and general reaction, is very violent, although the effusion into the joint is inconsiderable: in other cases the effusion, although proportionate to the intensity of the inflammation, yields as rapidly as the phlegmasia itself: finally, there are cases, unfortunately only too common, in which there is almost no inflammatory action, although there is an enor- mous synovial exudation, remaining for months, notwithstanding the use of the most energetic therapeutic measures. A similar occurrence is observed in peritonitis, in which the ascitic effusion is never greater than in cases in which the phlegmasia of the serous membrane has seemed to be exceedingly slight. Of this you have recently seen an example in a young woman in St. Bernard's Ward, who had hydroperitonitis for several months. Acute hydrothorax, that particular form of pleurisy of which I now speak, is evidently, in general, associated with a special state of the system, a sort of serous diathesis, which may either show7 itself only by effusion into the pleura, or which may simultaneously manifest itself by effusion into other serous cavities. Some of you no doubt remember the case of a man, sent to us by Profes- sor Rostan, who died in our wards from double pneumonia complicated with peritonitis. This patient entered the wards of my honorable colleague with extensive pleuritic effusion requiring paracentesis. At the request of Pro- fessor Rostan I performed the operation : a perfectly transparent serous fluid was withdrawn. The effusion having been reproduced, a second opera- tion was performed, when again the fluid was purely serous. Again there was a return of the effusion. The patient then came into my wards. He had at that time double pleurisy, and also subacute peritonitis, accompanied by considerable ascitic effusion. There was evidently in this individual a peculiar tendency to inflamma- tion of the serous membranes. At the autopsy we found the surface of the peritoneum covered with small granulations, which gave it the appearance of the skin of a plucked bird. The granulations had none of the characters of tuberculous products, of which no traces were found in any organ. Latent pleurisy is a subject on which I have now a word to say. In consequence of a chill, or, it may be, even without any appreciable determining cause, an individual is seized with rigors, general uneasiness, loss of appetite, pains in the back and limbs, and feverishness: he feels a slight stitch in the side, or perhaps he has no pain in the side: for a few days he has a short dry cough. These first symptoms continue a very short time, and are so soon forgotten by the patient that he makes no reference to them, unless you recall them to his recollection. The disease has, never- theless, pursued its slow course: the patient feels that he does not breathe freely, and that he pants on making the least movement: the dyspnoea is so great that he cannot lie on the sound side, or perhaps he finds it impos- sible to remain in the recumbent position: there is orthopnoea: possibly the dyspnoea is so slight that the patient is found lying flat on his back, and the oppression of the breathing may be much more appreciable by the phy- sician than by the patient. On examining the chest with the pleximeter and the stethoscope, you discover that there is effusion-sometimes enormous effusion-by which the heart, spleen, and liver are compressed and dis- placed, by which the chest is deformed in consequence of great distension of the affected side. These extensive effusions lead to very serious dangers. Sudden death may be one of the consequences. It is not unusual, I repeat, 584 PLEURISY: PARACENTESIS OF THE CHEST. for persons with extensive pleuritic effusion to sink all at once, without having had the breathing much oppressed, at any time, and without ever having had a threatening of suffocation. Death takes place from syncope. In corroboration of this statement, I appeal to the cases, published by my professional brethren, of sudden death occurring under such conditions as I have now described. I could also adduce several similar cases which have occurred in my own practice. The mortal faintings are explained by the great displacement of the heart occasioned by the mass of effused fluid. The heart, as I have told you, is forced out of its natural place: the aorta and large vessels are twisted in such a way as to impede greatly the current of the blood, so that under the influence of an exciting cause, such as the more or less abrupt movement of the body, the circulation is brought to a complete standstill. Perhaps also, death is sometimes induced by the forma- tion of clots in the heart and large vessels, which is liable to occur from the circulation of the blood being impeded. This opinion, which I announced long ago, has been verified by a case to which Dr. Blachet has directed attention.* This physician relates the interesting case of a patient who died suddenly in a faint. At the autopsy, a clot was found occupying the entire extent of the trunk of the pulmonary artery, and bifurcating, it stretched into the divisions of the third and fourth order of the left branch of the artery. In this case, the pleurisy was chronic: there was about a litre and a half of effused fluid: the heart was not displaced, and the sudden death was probably the result of the blood coagulating in the pulmonary artery. Although in many cases the patients do not complain of oppression in the breathing, although the existence of dyspnoea is not very apparent to the physician, extensive effusion may nevertheless cause death by asphyxia. In these cases, the asphyxia is slow, the consequence of great embarrass- ment in respiration, hsematosis not taking place in the affected lung, and being but imperfectly performed in the other, from its movements being necessarily disturbed by the liquid which fills the pleural cavities, presses on the mediastinum, and so diminishes the capacity of the other side of the chest. The only way to prevent a fatal termination is the true heroic practice of puncturing the chest and drawing off the effused fluid. This operation is quite free from danger. I shall, however, discuss the objections which have been brought against it, and shall, I trust, be able to show you that the imputed drawbacks are purely imaginary. Besides the case which led to my giving you the present lectures on pleurisy, you have seen many others, in which paracentesis of the chest was practiced under similar circumstances, and with equally happy results. The cases go on increasing infinitely; for on all sides, physicians are in haste to publish them. For my own share, I could cite a great many; some of them have occurred in my own practice, and others have been obligingly communicated to me by professional brethren. I shall restrict myself to giving you the particulars/of four cases. The first occurred in my own practice, and is now of old date: the second was reported in the wards of my honorable friend Dr. Horteloup, my col- league in this hospital: the third was communicated to me by my pupil Dr. Bonfils: the fourth you have recently had an opportunity of observing in my wards, and I shall specially call your attention to it, as it presents important peculiarities in respect of the question of temperature. On Saturday, 22d June, 1844, ray friend Dr. Patin came before six * Blachet: Union Medicale for February, 1862. pleurisy: paracentesis of the chest. 585 o'clock in the morning, to take me to see with him Madame Schlaguestad, living at 3, Rue Marcadet, La Chapelle-Saint-Denis. He had been sent for during the night to this patient, who at the fourteenth day of a pleurisy was so distressed for breath, that her life seemed to be in immediate danger. On Sunday, 9th June, she had felt uneasy, and had had a little pain in the left side of the chest. She had in a casual manner consulted a physician, who, considering that the breathlessness, pale countenance, and stitch in the side depended on chlorosis, ordered generous diet, good wine, and walking exercise. The unfortunate patient carried out only too scrupulously this fatal prescription; with energy she fought against the fever under which she was sinking: at last, on the eighth day of her pleurisy, conquered by the disease, she took to her bed, and called in Dr. Patin, who had no diffi- culty in discovering the nature of the case he had to deal with. There was complete dulness on the left side of the chest, from base to summit: the intercostal spaces were distended ; and the heart was pushed to the right side. Active treatment gave temporary relief. On Friday the 21st, she was in a somewhat improved state, after appearance of the menses; during the evening they ceased. In the night, the dyspnoea having become rapidly worse, and death seeming imminent, Dr. Patin was summoned from his bed. Dr. Patin found the patient sitting up in bed, supported by pillows: her face was pale and anxious: her eyes were wide open : her nostrils were in violent motion : and her respiration was extremely difficult. There was complete dulness of the left side of the chest, which was enormously dis- tended : in that situation, a blowing sound and segophouy were heard : the cough was moderate. The heart was beating under the cartilages of the right side of the sternum. The pulse was very rapid, and exceedingly weak. The amount of effusion was very great. Death was imminent. These were the circumstances under which I was called in. On my arri- val, the course to be taken was very soon decided on : paracentesis was immediately performed. By this proceeding, there was drawn off, without much difficulty, exactly two litres by measure [above two quarts]. You can easily understand the extraordinary relief experienced by the evacua- tion of these sixteen palettes of serosity. The poor woman was in fact restored to life. The heart had resumed its place, and the pulse was full and regular, though still somewhat frequent: the dyspnoea was gone. She lay almost in the horizontal position, breathed calmly, and had some desire to sleep. The dulness still continued on the left side of the chest, which now seemed smaller than the right side. The bronchophony and blowing sound remained as before. I prescribed digitalis, and recommended that the patient should have as little as possi- ble to drink. She had a perfectly quiet day : and during the night, slept seven hours. During some following days the digitalis was continued, and some purgative medicines were administered. On Tuesday, 25th, I again saw this lady. The clavicular region and the entire infraspinous fossa yielded a clear sound, and the respiratory murmur was heard in these situations : from the crest of the scapula to the base of the lung, segophony and bronchophony were audible. The patient had slight fever and a little dry cough, but there was no oppression of the breathing: she had appetite for food. The digitalis was ordered to be con- tinued ; and she was allowed to take light nourishment. Eight days later, the respiratory murmur was heard as high up as the middle of the infraspinous fossa : below that point, the sound was clear: near the angle of the scapula, there was very distinct segophony: lower down, there was a blowing sound and bronchophony: there were no rales : 586 PLEURISY: PARACENTESIS OF THE CHEST. the cough was still dry. Although the appetite was very good, the fever continued. I ordered a blister to be applied to the back, suspended the other treatment, and prescribed a decidedly nutritious diet. Sixteen days after the operation, so great was the patient's restoration of strength, that she was able to walk to the residence of a relation at Clignancourt, a dis- tance of more than two kilometres [more than a mile and a half], remain there during the day, and return on foot in the evening, without being much fatigued. I saw her three days after this imprudent proceeding, when she was very well, had an excellent appetite, and had neither cough nor dyspnoea. Posteriorly, there was still dulness in the lower part of the side which had been the seat of the effusion, but the respiratory murmur was everywhere audible. The following is the history of the second case. On 5th January, 1854, a man, aged thirty-six years, came into Dr. Horteloup's wards in the Hotel- Dieu. He said that he had been ill for three weeks; but that he had had cough for six months. Upon interrogating him as to his hereditary ten- dencies and personal antecedents, nothing was elicited indicative of the tuberculous diathesis. It appeared that without any cause appreciable to the patient, he had been seized three days prior to his admission to the Hotel-Dieu with shortness of breath and wandering pains in the chest, but without having any stitch in the side. He had at that time no fever, and was able to continue his ordinary work. In consequence of increased diffi- culty in breathing, he applied for admission to the hospital. On admission, he was suffering from extreme anxiety and suffocative symptoms, speaking with difficulty, and in a short, jerking voice. His countenance was pale and blue : the extremities were cold. At the first examination, the chest was evidently distended on the right side. There was complete dulness from summit to base, both before and behind-a little less, however, below the clavicle, and in the upper part of the verte- bral hollow. In that situation, and there only, was heard a slight distant blowing sound: the respiratory murmur was everywhere absent. The pulse was quick and small. A large blister was applied to the side; and a bottle of Seidlitz water was prescribed. There was no change in the state of the patient by the 10th January, except that he felt better. Bear this in mind: it is a special circumstance, to which I have already directed your attention, and to which I shall have to return. The blueness of the face, especially ot the lips, was even more decided. Asphyxia seemed imminent. Under these circumstances, my honorable friend Dr. Horteloup asked me to see the patient. I stated that I considered paracentesis to be urgent; and, consequently, it was at once performed by M. Dal Piaz, interne. Twenty-two palettes, or in other words 2500 grammes [more than two quarts and a half] of lemon-colored serosity, having a somewhat dirty tinge, were drawn off. Immediate relief was experienced. The plessimetric and stethoscopic phenomena were at once modified: there was a diminution in the dulness, and a blowing sound as well as mucous rales were audible. I prescribed the tisane of digitalis. Eight days afterwards, when I saw the patient, he was so much improved in appearance, that I did not at first recognize him. He had regained a plump, healthy appearance. I found him lying on his back. On 2d February, he was dismissed from the hospital at his own request. His general state was then very satisfactory. Some harshness of sound remained in the right side of the chest, but the vesicular murmur was heard from base to summit. The following case, communicated by Dr. Bonfils, is not less conclusive than those I have now related to you. pleurisy: paracentesis of the chest. 587 "On the 10th or 11th July, 1861, Madame L., aged fifty-four, residing in the Rue Saint-Honore, was seized with serious pulmonary symptoms. The symptoms were of the nature of those which generally accompany the onset of purely inflammatory pleurisies, viz., rigors, general pains, burning fever, extreme anxiety, headache, and complete insomnia. The patient complained of an acute pain in the side. Respiration was anxious and panting, the embarrassment being to such a degree as to amount to orthop- noea. When summoned in haste on the morning of the 13th July, the symptoms which I first observed at once directed my attention to the respiratory organs. On examining the chest, I detected, without any difficulty, that there was extensive effusion into the left pleura. The intensity of the fever, and the general constitutional disturbance, showed the serious nature of the case. Blisters, purgatives, diuretics, large doses of the tincture of squills and of digitalis, did not in any degree impede the progress of the effusion, which increased with terrible rapidity. " On the 18th, the seventh day from the beginning of the attack, the effusion filled the pleural cavity, coming as high up as the crest of the scapula, and displacing the heart, the apex of which was beating to the right of the median line of the sternum. There was complete dulness throughout the whole of the left side of the chest, where no respiratory sound was heard. " The tendency to lipothymia being manifest, and syncope threatening, I had no hesitation in proposing paracentesis to the family. My excellent master, Professor Trousseau, kindly gave me his aid on the occasion. The operation was at once performed ; and 1750 grammes [nearly two quarts] of serosity flowed from the canula of the trocar. " Immediately after the evacuation of the fluid, respiration was heard throughout the whole of the affected side : and percussion gave a resonant sound where before there was absolute dulness. The heart had returned to its place, and the serious symptoms, so threatening before our interven- tion, had disappeared. The results of the operation were all that could have been desired. " Next morning, the general state of the patient was satisfactory; and respiration was performed with perfect freedom. I ought, however, to add, that the fluid was reproduced to a small extent; but the daily exter- nal application of the tincture of iodine speedily caused it to be absorbed. Recovery was complete on the ninth day after the operation." This is the case to which I referred. It is interesting, not only because we have, like in many other cases, had the opportunity of clinically observ- ing that convalescence was the direct result of paracentesis of the chest, but especially because examination of the temperature before and after the operation, demonstrated this convalescence materially, it may, in fact, be said, mathematically. The coincidence of the definitive return to the normal temperature with the evacuation of the fluid was at once proof of the cure of the patient, and of the curative effects of the operation. On 11th June, 1864, I received in St. Agnes's Ward, a young man, aged twenty-three, of very delicate constitution, thin, and pale ; but who, neverthe- less, did not cough, and who presented none of the rational signs of tuber- culization. Fifteen days before he came into the hospital, he had a slight stitch in the left side, accompanied by a little fever. He had not been confined to bed ; and was able to walk to the hospital. Posteriorly, on the right side of the chest, as high up as the spine of the scapula, I found abso- lute dulness without any blowing sound or segophony ; there was also dul- ness in front. Within a small space, not larger than a five-franc piece, situated in the upper part of the chest, near the sternum, I perceived 588 PLEURISY: PARACENTESIS OF THE CHEST. skodaic resonance. For twelve days, the state of the patient was almost stationary, the effusion, however, increasing rather than diminishing. From the effusion being on the right side, from the patient being of feeble constitution, and subject to fever every evening, I dreaded pulmon- ary tuberculization : and determined to resort to paracentesis. The opera- tion was performed by Dr. Peter, then my chef de clinique, on the morning of the 26th day of the attack, the temperature being 38.7°. There was withdrawn from the chest 750 grammes of serosity, which by pressure in a linen cloth, yielded three grammes and a half [44 grains] of moist fibrin. On the following days, the respiratory murmur was heard throughout the chest, mingled with some subcrepitant rales behind on the right side: in front, in the upper part of the chest, was heard the crackling like that of new leather. On 8th July, the patient left the hospital perfectly recovered. Let me now tell you what was learned in this case by thermometrical examination. I have already told you that just before the performance of the operation the temperature was 38.7° : on the evening of the previous day it had been 38.6°, and for eight days it had always kept about that in the evening, falling in the morning only from four- to six-tenths of a degree. On the very evening of the operation, however, in place of rising, as before that date it had usually done, it fell to 38°: next morning, it continued to descend, and fell to thirty degrees and two-tenths-that is to say, the temperature became normal. In the evening, it fell four-tenths, being then 38.8° : and that was the temperature next morning, forty-eight hours after the operation. From that time, till the day on which the pa- tient left the hospital, there was a physiological temperature varying between 37.6° and 36.6°. As temperature is the best criterion of the febrile state, and as in the case now under consideration the sudden and permanent fall was coincident with the thoracocentesis, it may be said that the convales- cence of the patient began immediately after the operation, and that the recovery dated from the evacuation of the fluid.* In pleurisy, and, in general, in all inflammations of serous membranes, thermometrical investigation does not furnish a curve so distinctively charac- teristic as in certain diseases of regular type, as, for example, in fevers. However, in pleurisy, as well as in peritonitis, it is useful in enabling us at once to distinguish these diseases from certain very painful affections which they simulate. If we find that the temperature remain normal in a patient suffering from intense pain in the side or abdomen, we may, in the former case, conclude that he has pleurodynia, and not pleurisy; and in the latter, that the cause of the pain is colic, and not peritonitis. On the contrary, we may announce that there exists pleurisy or peritonitis, as the case may be, if the thermometer rise to, or above 38°, or to 38.5°, during the first hours of the attack. I shall now resume my subject-paracentesis of the chest. The necessity for performing paracentesis in those cases of excessive pleu- ritic effusion in which there is a danger of the occurrence of sudden death, is now admitted by all real practitioners; but its utility, nay, its necessity, is also beyond doubt, when the object is to ward off'those accidents, which, as I stated at the beginning of this lecture, may arise from continuance of the effusion. In such cases, it is often the only means of preventing a fatal issue, or of prolonging life. Experience shows that even in the simplest case of pleuritic effusion, resolution requires a long time, even when the effusion is small in quantity. * Duclos : Quelques Recherches sur 1'Etat de la Temperature dans les Mala- dies-Thfese (1864); where this case and the thermometrieal scale relating to it are given. pleurisy: paracentesis of the chest. 589 We all know how great a difference there is in this respect between pneu- monia and pleurisy: the march of the former is as much characterized by rapidity, as is the march of the latter by slowness, at least in the decline of the attack. All practitioners have been struck with this fact; and it is not unusual to see patients-even when treated most energetically and most rationally-retain for a month, for two months, or for a longer period after the termination of the acute stage, obscurity in the respiratory sound, and pleuritic blowing, testifying not only to the existence of false membranes, but also to the presence of a certain quantity of the effusion. Suppose, gen- tlemen, that you had to do with a case in which the quantity of fluid effused was not small, but, on the contrary, very considerable, you can understand why resolution should be necessarily slower in the one case than in the other. Suppose, for example, that the pleura contains two or three litres of serosity, it would not be surprising for three, four, five, six months or longer to elapse, before the effusion had entirely disappeared : this greater slowness in the absorption is perhaps as much dependent on the pressure exerted by the excessive quantity of fluid upon the serous membrane by which absorption has to be performed, as by the mere greatness of the quan- tity. The effusion does not remain harmlessly in the cavity within which it is inclosed-it produces febrile action; and the longer the effusion remains, the longer will the patient continue in a feverish state. The nutritive func- tions will be disturbed ; for, as has been clearly shown by the beautiful experiments of M. Cl. Bernard, there is a sufficient cause of fever, whenever digestion is badly performed, whenever the gastric secretions lose their physiological properties, and become unfit to accomplish those operations in vital chemistry which it is their office to perforin in the process of chymi- fication. Fever continuing from the presence of pleuritic effusion, will ultimately exhaust the individual, causing him to sink in a hectic state. This hectic fever invariably occurs where there is suppurative pleurisy, or empyema, as it is called. Although serous pleuritic effusion, very great in quantity, may exist for a long time without becoming purulent, cases occur, particularly in children, in whom this transformation takes place, more or less, the pleurisy remaining simple, at least to the extent of not being ex- pressive of any diathesis. Gentlemen, as you are aware, at the beginning of an inflammatory affec- tion of a serous membrane, the microscope scarcely discloses any of the constituents of pus; but if the malady continue, the microscope will enable us to see pus-globules, which will go on becoming more and more numerous as the inflammation advances. The pleural serous membrane, when it has been for a long time the seat of inflammation, at last secretes pus, just like the cutaneous and mucous membranes. At the beginning of a bronchial catarrh, there is no pus in the sputa; but in a short time, the expectoration becomes muco-puriform. It is, therefore, our duty, not to allow an inflammation of the pleura to go on too long, otherwise we shall see an effusion become purulent which originally was serous. This fact ought to cause us to decide to operate in cases in which there is a large quantity of effusion ; for as I have just said, these are the cases in which resolution will be slowly accomplished. There are not only pleurisies which become purulent from the mere con- tinuance of the state of inflammation, but there are also pleurisies which from their nature are purulent from the first. These suppurative pleurisies now solicit our attention for a few minutes. In virtue of a special condition of the system, a condition which often results from the puerperal state, and is also induced by the eruptive fevers, by small-pox, but still more frequently by scarlatina, inflammatory affec- 590 pleurisy: paracentesis of the chest. tions of serous membranes-the serous membranes which cover the great splanchnic cavities and the synovial membranes of the joints-have a very great tendency to become suppurative. For example, in women who have been recently delivered, an articular affection which in any other state of the system would have been nothing more than simple arthritis, at once becomes a purulent arthritis. A pleurisy, which in ordinary circumstances would have been a simple pleurisy, becomes purulent. Those of you who have read Dr. Charrier's thesis know how common these suppurative pleurisies were in 1854.* A short time ago, we received into our wards a woman who had been confined eleven days previously in the Maternity Hospital. On the very day of her return to her lodgings, she was seized with pain in the side, shivering, and intense fever. On the fifth day from this attack, when she came to the Hotel-Dieu, I found that there was pleurisy of the left side. The necessity for tapping very soon became urgent: the operation was per- formed on the ninth day from the beginning of the symptoms, when there was drawn off a dirty-looking fluid resembling thick broth. I have no doubt that it would have been found to contain the constituents of pus, had it been examined by the microscope. After some days, there was a return of the effusion : in about a fortnight, the place where the puncture had been made reopened of itself, and gave exit to a large quantity of fetid pus. The woman died. At the autopsy, we found, on opening the thorax, that the pleural cavity communicated with the wound made by the trocar, and was filled with gas and fetid pus; on the interior surface of the lung, between the two lobes, there was a circumscribed pleurisy, which formed a sort of cyst containing nearly two hundred grammes [about twenty-five fluid ounces] of pus. It is evident that the suppuration could not in this case be attributed to the puncturing of the chest, as the suppuration had taken place in the encysted pleurisy, as well as in that which occupied the great pleural cavity originally emptied by the paracentesis. The purulent pleurisy was produced under the influence of a special diathesis, or suppurative tendency which exists in puerperal women, and is well known to all physicians. As I have already reminded you, the same thing takes place in eruptive diseases. You know-and I mentioned the circumstance when lecturing on small-pox-that in that disease the slightest inflammation is very apt to become suppurative. A very frequent sequel of confluent small-pox is the formation of numerous abscesses in various parts of the body, which go on forming for six weeks, two months, three months, or eVen longer. Patients who have escaped terrible attacks of the disease itself, sink from these ab- scesses, exhausted by interminable colliquative suppuration. But it is principally as a sequel to scarlatina that the suppurative ten- dency shows itself in serous and synovial membranes. Thus, scarlatinous arthritis, generally particularly mild, and much shorter in its duration than ordinary articular rheumatism, assumes in some cases a very violent char- acter, terminating in death; and when at the autopsy the joints are opened, they are found to be filled with pus. In these cases we also meet with suppurative pericarditis. Finally, the suppurative tendency shows itself by purulent effusions into the cavities of the pleurae. I directed your attention to this important point when lecturing on scar- latina. To the cases which I then brought under your notice let me add the following. * Charrier : Sur 1'Epidemie de Fievre Puerperale Observee en 1854 a la Maternite de Paris. PLEURISY: PARACENTESIS OF THE CHEST. 591 On the 9th September, 1849, a boy six years of age, who had been in a very alarming state from the end of August, was brought to my wards at the Hopital des Enfants Malades. On the 20th of that month he was seized with scarlatina; the attack seems to have been very serious. I was at once struck with the general anasarcous appearance presented by the patient: I discovered extensive effusion in the left side of the chest. A large blister was immediately applied, and an infusion of digitalis was ordered to be taken in a tisane. At the end of eight days his state was much worse. The poor child, sitting up in bed, supported by pillows, was panting for breath, and with difficulty answered in monosyllables the ques- tions addressed to him. His face was of a livid blue, and the extremities were cold. The pulsations of the heart were quick and small; the pulsa- tions of the radial arteries could no longer be felt; and everything seemed to indicate speedy death. There was complete dulness throughout the whole of the left side of the chest, which was evidently distended; but the arched appearance of the chest and the obliteration of the intercostal spaces were masked by cedem- atous infiltration of the subcutaneous cellular tissue. In front, where alone auscultation was practicable, no respiratory murmur could be heard. The heart was completely displaced, the apex beating at the right edge of the sternum. The tongue, white at the edges, was rather dry and rough in the middle. The motions were loose. Paracentesis was urgently demanded: I therefore operated at once, and withdrew a litre [more than a quart] of pus. The child was immediately relieved, and was enabled to sleep, lying on his back. During the day, he was obviously much better. Immediately after the operation, the heart moved towards its position in the left side, and we heard blowing at the summit of the lung. During the two following days the improvement was great. The general puffiness had diminished, particularly that of the face, where lividity had given place to a well-marked rosy tint. The pleura, nevertheless, still contained a very considerable amount of effusion, and the heart, though showing a tendency to take its normal position, was still felt beating in the median line. During the succeeding days, the general oedema sensibly decreased ; but there was little change in the chest symptoms. Although the appetite returned, the general debility went on increasing. Between my visits of the 19th and 20th September, he had, each twenty-four hours, four loose motions; and this diarrhoea continued till his death, which occurred on the twenty-fourth. At the autopsy, we found the pleural cavity filled with a purulent fluid, and both the costal and the pulmonary pleura were coated with false membrane. The lung was shrunk up, and the bronchial glands contained tubercles. Suppurative pleurisy is essentially a serious disease, and indeed generally proves fatal, the cases in which recovery takes place through the unaided efforts of nature being quite exceptional. This statement is equally appli- cable to cases in which the disease is purulent from the beginning, and to simple pleurisies which become purulent. It sometimes happens that the pus which has been poured out into the chest finds an outlet for itself through a perforation of the bronchial tubes. We had an example of this in a patient who lay in bed 11 of St. Agnes's Ward, whom you have seen bringing up by the mouth daily large quantities of pus. To give easy exit to the pus, it was sufficient for the patient to lean over the bed with the head down, as you have seen many times. This man had consider- able hydrothorax, but was otherwise in good health. He was, on his own request, allowed to leave the hospital. 592 pleurisy: paracentesis of the chest. Recall to your recollection the history of a man whose case I related when speaking of the differential diagnosis of peripneumoniae and pleural vomicae-a case I saw in consultation with Dr. Bordes. I must add, that these fortunate cases are of an altogether exceptional class, and that most frequently hydrothorax, particularly in the adult, sooner or later terminates in death. Even in these cases of empyema, paracentesis of the chest-and this is the point I wish to come to-even in these cases, the operation renders great service. Though it certainly does not produce the undoubted benefits which it yields in excessive effusion in simple pleurisy, it at least retards the fatal termination, and in some cases leads to recovery, when there is adopted at the same time a particular means of treatment of which I shall have to speak. Of course, I do not include cases of suppurative tubercular pleurisy, nor of pleurisy in which the purulent character is dependent upon caries of bone; but even in such cases, thoracocentesis is of some use, as I shall afterwards show. At present, we have only to consider cases of pleurisy occurring under the least unfavorable circumstances-conditions which I have just pointed out. In an interesting work, my late lamented colleague Dr. Aran, gave an account of the successful results of this mode of treatment. * Similar cases are given in various monographs. You will find several in the inaugural thesis of Dr. Lacase du Thiers, and,a considerable number have been col- lected by Dr. Boinet. f The following case, which occurred in my private practice, deserves to be stated. The widow of Dr. Pauly, an estimable Parisian colleague, when suffering from the fatigue of attendance on her husband (who had died of phthisis), was seized with pleurisy in the right side, accompanied by great effusion. Chomel having been called in, recommended active treatment; but as the disease became more serious, he sent for me to perform paracentesis, if I should think it necessary to do so. There was great oppression of the breathing: the effusion filled both sides of the chest. I operated, and with- drew a great quantity of somewhat muddy serosity. In two or three days, there was as much effusion in the chest as there had been prior to the opera- tion of paracentesis. I nevertheless waited for fifteen days, at the end of which period, it became urgently necessary to repeat the operation. This time the fluid was very turbid, opaline, and evidently contained pus. I was glad that I had given exit to it. A third time, the effusion returned ; and a third time it became necessary to perform paracentesis. The operation was performed by Dr. Boinet and me : on this occasion, we followed up the withdrawal of the fluid by injecting a solution of iodine into the pleural cavity. Some months afterwards, I saw the patient: she had then regained her plump appearance, and stated that she was restored to her usual health. But it is chiefly in children that we can count on success. At a meeting of the Hospital Medical Society, Legroux and I each presented a child suc- cessfully treated for suppurative pleurisy, by a long course of injections of iodine. Let me give you an exact account of the'case of my little patient. On the 13th of January, 1853, Edme Belize, aged six years, was attacked with pleurisy, and was treated by Dr. Fleury. Notwithstanding the most energetic treatment, the severity of the symptoms increased, and towards the end of the month Chomel was summoned in consultation. Drs. Fleury and Chomel detected thoracic effusion which completely filled the right * Aran: De 1'Utilitede 1'Association des Injections lodees a la Thoracocentese- in the Treatment of Purulent Effusion consecutive to acute and chronic Pleurisy, &c. f Archives Generates de Medecine, 1853. pleurisy: paracentesis of the chest. 593 pleural cavity. The patient had a great deal of fever and dyspnoea. Diu- retics, contra-stimulants, and cutaneous revulsives were employed with su- perabundant energy; but still, day by day, the effusion seemed to increase, and by the end of the month, there was general anasarca and great orthop- noea. It was under these circumstances that I was summoned in consulta- tion. Dr. Fleury and I being of opinion that paracentesis of the chest offered the only chance of saving the patient, immediately performed the operation, withdrawing nearly two litres of inodorous, creamy pus. Great relief fol- lowed : however, fifteen days later, the pleural cavity was again filled with effusion ; and by the middle of June, the heart and liver had become dis- placed. The symptoms being very serious, the operation was again had recourse to, and with the same immediate good results. The pus which was withdrawn had the smell of rotten eggs. At the beginning of July, there was a reproduction of the effusion, but there was tympanitic resonance on the right side, as high up as the subcla- vicular region : succussion produced Hippocratic gurgling: there evidently existed hydrothorax. We resolved to wait, but on the 15th August, there was so great an increase in the severity of the symptoms, that we decided to puncture the chest a third time, and to leave a canula in the wound, so that the treatment by iodine injections might be pursued. Upon this occa- sion, we withdrew nearly two litres of horribly fetid pus, mixed with bub- bles of gas. We introduced into the wound a small canula, slightly conical, three centimetres in length, having externally a button-shaped extremity : the orifice was closed by a metallic stopper which fitted as tightly as a nail fits which is driven into a hole. The stopper was withdrawn every morning, to allow the pus to flow, after which there was injected a mixture composed of nearly thirty grammes of tincture of iodine, forty grammes of water, and from twenty to thirty centigrammes of the iodide of potassium.* For six months the quantity of pus varied from 100 to 300 grammes. In general, it was not fetid. From time to time there was no purulent secretion ; fever then supervened, and a dreadful putrid smell came from the canula. At the end of six months, that is to say, in February, 1854, it was ob- served, that when the fluid was injected into the pleural cavity, it passed into the bronchial tubes, and even into the mouth of the child. The solu- tion of iodine was then replaced by an injection of a solution of chlorine in water: afterwards, aromatic wine was used. In each successive month, however, there was a visible diminution in the quantity of fluid: the chest was contracted, and the vertebral column was inclined to the right. Strength and appetite returned. A nutritious diet was given : also, occasionally, cinchona wine and fish oil. Finally, in July, 1854, nearly eleven months from the date of the intro- duction of the canula, eighteen months from the beginning of the malady, there was almost no discharge; and by the 1st September, it had com- pletely ceased. Upon introducing a probe, it was found that the fistulous passage had closed. The canula was withdrawn. When I brought this case under the notice of my colleagues, the child was in perfect health. Respiration was heard throughout the whole of the right side : the flattening of the chest and curvature of the vertebral column, so conspicuous six months previously, were becoming less and less day by day. * The Tincture of Iodine of the French Codex is a solution of one part (by weight) of iodine in twelve of alcohol. vol. i.-38 594 pleurisy: paracentesis of the chest. In this remarkable case, purulent effusion three times necessitated recourse to paracentesis : perforation of the lung took place; a solution of iodine was injected more than two hundred times, and there were nearly as many chlor- inated and aromatic injections used: in the end, however, the cure was complete. Let me call your attention, as I called the attention of the Medical So- ciety of the Hospitals, to the extraordinary quantity of the purulent secre- tion, which may be estimated at a daily average of 200 grammes for about 200 days, which is the enormous total of 40,000 grammes [more than 40 quarts]. You can understand how essential was constant and copious nourishment to enable the child to struggle with this prodigious drain on the system. I could lay before you two precisely similar cases occurring in children: one occurred in the practice of Dr. Mousset-a case of empyema following ty- phoid fever; and the other, in the practice of Dr. Vigny-a case of em- pyema following chronic catarrh. In both of these cases, a more speedy cure was obtained than in the case the full particulars of which I have just re- lated. The medico-chirurgical treatment adopted was similar. I shall only cite one other example. The subject was a young lad, to whom I was called by Dr. Bonfils. He was an American, nine years of age, who, about the end of May, 1862, was attacked with pleurisy, well marked, simple, and, in the first instance, of ordinary severity. The pleurisy was on the left side. As there were no unusual symptoms, the case was considered benignant, and was treated in accordance with that impression. After some time, however, it was observed, that the effusion increased in place of diminishing, and caused the breathing to become more and more embarrassed: the fluid nearly filled the pleural cavity, and the heart was pushed out of its place. Dr. Bonfils was called in on the 10th June ; the diagnosis did not present any difficulty. The disease made rapid progress; and on the 17th June, Dr. Bonfils looking to the manner in which matters were advancing, think- ing that the chest should be tapped, asked me to consult with him on the case. The effusion occupied two-thirds of the left side of the chest, and forced the heart to the right: there was great difficulty of breathing. To hesitate was impossible: paracentesis was an urgent necessity. The operation was at once performed by my colleague, when there issued from the canula a continuous gush of pus, to the extent of 600 grammes [nearly a pint and a quarter]. This result did not surprise me: I had foreseen it, but had reserved my opinion upon the nature of the fluid. I was justified in believing that the case was one of purulent pleurisy, from the continuance of the effusion, and also because pleurisy seemed to have supervened on an attack of measles, which the child had had some time previously, but from which he had not made a complete recovery. Immediately after the operation, the breathing became easier: the vesicu- lar murmur was heard where an instant previously it was inaudible: there was thoracic resonance, and the heart was regaining its natural position. During the following ten or fifteen days, the effusion, remaining moderate in amount, respiration seemed to be freer: the general state of the patient was not getting worse, so that there was room to hope that the malady would of itself subside. Ere long, however, unfavorable symptoms reap- peared. From 17th June to 16th August, complications of the most alarm- ing seriousness occurred: however, as at intervals, a certain amount of amelioration in the general aspect of the symptoms was observable, we pleurisy: paracentesis of the chest. 595 remained spectators of the struggle, waiting for the occurrence of some positive indication to interfere. About the middle of July, the patient seemed, for twelve days, to be getting into a better state, when about the beginning of August, he grew worse, and the danger became imminent. On auscultating the chest posteriorly and laterally, there was heard a blowing-sound, tubal and amphoric, the maximum intensity of which was heard in the upper part of the vertebral hollow. On percussion, a slight degree of resonance was observed in some scattered situations, which led to the supposition that the effusion was small in quantity, and that we had to do with one of those circumscribed pleurisies in which we find false mem- branes infiltrated with pus, rather than a collection of purulent fluid. There was the greater reason to take this view of the case, from the circumstance, that upon that side of the chest there was deformity and flattening pos- teriorly, while anteriorly and laterally there was slight arching, formed by projection of the ribs, which were abnormally separated from one another. In this situation, thedulness was complete ; and no respiratory murmur was audible. The heart was out of its place, and forced upwards. Although the state of the patient was alarming, I hesitated to interfere surgically, as the diagnosis of the local lesions was beset with causes of great uncertainty. The question was : might not the trocar, in the event of a new puncture being made, come upon a mass of false membrane, which would prevent the flow of the fluid ? However, as the deformity, the arch- ing (which day by day became more and more decided in front), the com- plete dulness, and the absence of every kind of sound, made it evident that there was circumscribed effusion-as this effusion was increasing-and as the dyspnoea was very great-on the 19th August, two months after the first tapping, Dr. Bonfils saw the necessity for resorting a second time to the operation. He withdrew 300 grammes of thick phlegmonous pus, similar to that which was evacuated on the 17th June. The operation again gave immedi- ate relief, although there was no modification in the signs furnished by aus- cultation and percussion. Some days later, at the end of August, a small fluctuating tumor formed several centimetres above the cicatrix of the wound made by the trocar: it occupied an intercostal space, the skin over which was of a violet color. On the 1st September, this abscess was opened by the bistoury, and in this way, a pleural fistula was established, from which, for ten weeks, there was an exudation of pus, at first very tenacious, afterwards becoming serous, but never presenting an unhealthy character, and always decreasing in quantity. From this time, the general health became satisfactory, and the cure of the local affection showed steady progress. The effusion steadily diminished in quantity, while at the same time the chest underwent that deformity which is usual under similar circumstances. In the month of October, the patient was able to go out; and Dr. Bonfils then met him playing in the gardens of the Tuileries. Three months later, the deformity of the chest had disappeared. A few days ago, this child was brought to me in my consulting-room ; and I found that his cure was as complete as possible, and that his health was excellent. If there be one species of purulent pleurisy which seems to baffle all the efforts of medicine it is assuredly that species to which puerperal women are subject. The majority of such cases terminate in death, which is indeed their almost inevitable issue. Still, even in these cases, paracentesis affords a chance of recovery, as is shown by the following case. 596 pleurisy: paracentesis of the chest. At the beginning of 1858, Dr. Rousset did me the honor of calling me in to consult with him in the case of a young lady, who, nine days previ- ously, had been delivered of her first child. On the fifth day after de- livery, she was seized with fever and slight pain in the left side : this was the beginning of a pleuritic attack. Dr. Bayer was called in : treatment, at once the most active and the most rational, was resorted to. The effu- sion advanced with the most frightful rapidity: on the fifth day of the disease, the symptoms assumed such intense severity, that any medical interference seemed useless. Dr. Rousset, and M. Bouley (my colleague at the Academy of Medicine, and a relation of the patient), thought that possibly paracentesis of the chest might offer a chance of prolonging life. When we met in consultation, the pulse was quick, and so small, that death seemed imminent: it was impossible not to see that the patient had puru- lent effusion. We were aware that the puerperal state imparted a serious character to the local disease: but life was ebbing, and the operation could not in the slightest degree diminish the patient's chances of recovery. I performed paracentesis, and withdrew nearly 1500 grammes of a tur- bid, semi-purulent fluid. Immediate relief was experienced. The pulse regained its volume, and lost its frequency. The patient seemed to return to life, and testified her gratitude by a look which seemed to me of very good augury. There was still, however, very high fever, and some dysp- noea. Four days later, the fluid reaccumulated ; and the orthopnoea be- came exceedingly urgent, although life did not seem to be placed in imme- diate jeopardy. I again tapped, the operation being performed in the intercostal space immediately below that in which it had been previously practiced : upon this occasion I withdrew 1200 grammes. I closed the wound in the same way as on the first occasion ; being prepared to incise an intercostal space, and use injections of a solution of iodine, should the purulent secretion be renewed with similar rapidity, particularly if it as- sumed a fetid character. The case went on favorably : the fever abated : the appetite returned ; as did likewise a hopeful, cheerful state of mind. During the next fort- night, I observed a slow reaccumulation of the pus. There was after this a little inflammatory action in the situation of each of the two punctures, and this was followed by slight fluctuation. Some days later, both wounds reopened, and yielded a large tumbler of perfectly inodorous pus. Daily, for a month, a large quantity of similar fluid was discharged. One of the wounds then closed ; and for more than four months from that date, every two or three days, there was found in the bandage which encircled the patient's body, at least two or three spoonfuls of tenacious, inodorous pus. At last the wound finally closed. Some days after this occurred, there was dyspnoea, and increased uneasiness : then, one day, the patient brought up by the mouth nearly a tumbler of pus. The pleural effusion, perforat- ing the lung, had found exit by the bronchial tubes. I was not without anxiety; but I was soon reassured by seeing that the purulent expectora- tion rapidly diminished in quantity, and did not assume any degree of fetor. This vomica was not healed till the next winter, nearly a year after the first operation. Next year, the young patient went to Cauterets, whence she proceeded to Mentone, where she passed the winter: she is now about to go to Nice. At present, she is in quite as good health as before her marriage ; but she easily takes catarrh, easily becomes feverish, and has sometimes oedema of the inferior extremities, which yields after some days of violent diarrhoea. The chest, which had become deformed, as a conse- quence of the disease, has regained its normal configuration. She gener- pleurisy: paracentesis of the chest. 597 ally has mucous rales, but there is nothing to lead to the belief that she has tubercles. It is not necessary to repeat the details of a case which I referred to in my lectures on scarlatina : the patient was a child, whom Dr. Blanche and I successfully treated by paracentesis for suppurative pleurisy supervening in the course of the exanthematous fever. But as an additional example of the utility of tapping the chest in scarlatinous empyema, and as one among other similar cases which I might relate, I ask you to allow me to read an account of one of the cases which Dr. P. Brotherston has pub- lished in the " Edinburgh Monthly Journal of Medical Science," for 1853. " In October, 1853," says Dr. Brotherston, "a boy, four and a half years of age, was attacked with serious chest symptoms after scarlatina. The disease was in the left side, where there was dulness and an absence of res- piratory sound. The patient had a very painful cough, and oedema of the extremities. He slept badly. The application of leeches and the admin- istration of diuretics failed to give any relief. On the 2d November, paracentesis was performed: the puncture was made with a small trocar, between the seventh and eighth ribs, at an equal distance between the sternum and the spine. There was a flow of thick, yellow, healthy pus: the quantity could not be estimated. A large piece of sponge, cut out in the centre, and soaked in hot water, was applied to the orifice of the can- ula : eight hours afterwards, not only was the sponge saturated with pus, but pus had soaked through the child's clothes. Rapid improvement took place, and the wound closed. On the 15th November, there was distinct fluctuation in the situation of the puncture : a new opening was made, which afforded exit to ten ounces of healthy pus. The wound remained open for about a month, and discharged during the whole of that time. The child was restored to perfect health." Before proceeding farther I must call your attention to the fact, that in a large proportion of the numerous cases of recovery which I have brought under your notice, the pleurisy was on the right side. In 1860 Aran published a work, from which it appeared that, when the effusion is on the right side, paracentesis produces only a temporarily bene- ficial effect, as the fluid reaccumulates; or, if at first all has gone on well, in a short time tubercles supervene. It is very remarkable that Hippocra- tes noticed this fact without trying to explain why the probability of recov- ery is greater when the operation is performed on the left side.* Be the explanation what it may, I confess that my attention had not been called to the fact till it was pointed out by Aran; and now that I bestow more consideration upon it, I am obliged to admit-without, however, being able to explain the circumstance-that effusions on the right side are most com- mon in tuberculous subjects: but if Aran was unfortunate in his cases of paracentesis for effusion on the left side, you have seen that, by a chance which I cannot explain, I have cured a large number of patients with pleu- risy on the right side-very serious pleurisies, giving rise to effusions enor- mous in quantity, and of a purulent character. Hitherto, gentlemen, we have been exclusively occupied with cases of suppurative pleurisy; but your surgical teachers have told you that empy- ema may be the consequence of a traumatic lesion of the chest, and they have likewise stated that these are the cases in which paracentesis is indi- cated. A patient, who occupied bed 1, St. Agnes's Ward, afforded us a remark- able example of traumatic empyema. The man to whom I refer was a car- * Hippocrates: De Morbis, lib. ii, $ 15. 598 PLEURISY: PARACENTESIS OF THE CHEST. man, of robust constitution, who was admitted to our clinical wards on the 12th November, 1856: on admission, his malady was of six weeks' dura- tion. He got violently squeezed and bruised between two carts, and had to be carried to his place of residence. A medical man who was called in ordered (on the day on which the accident occurred) leeches to be applied to the injured part, and on the following day he took a large quantity of blood from the arm. These bleedings did not calm the acute pain which the patient experienced, and which continued for a fortnight afterwards. No amendment having followed the application of large blisters to the chest, this individual was sent to the Hotel-Dieu. On his admission I found that there was very marked deformity of the chest, and that the right side was considerably arched. There was dulness on percussion, extending from the base of the chest to the crest of the scap- ula behind, and to the subclavicular fossa in front: in that situation there was an abnormal degree of resonance. On auscultation it was found that the vesicular murmur was absent in the lower part of the chest: in the in- fraspinous fossa there was a blowing sound and aegophony: we also heard metallic tinkling in the infraspinous fossa, and the sound of fluctuation pro- duced by succussion, indicating the presence of air and fluid in the pleural cavity. The liver, pushed out of its normal position, extended far beyond the margins of the false ribs. The patient coughed a great deal: the sputa were bloody and rusty, mingled with frothy aerated matter. Respiration was rapid and painful. The pulse was small, and about 120 in the minute. The countenance was flushed and excited. The patient's strength did not seem to be exhausted. The physical signs showed beyond doubt that there was pleurisy, complicated to a certain extent with pneumonia; and also that there existed a communication between the bronchi and the pleural cavity. Looking to the circumstances under which the malady originated, I concluded that the effusion was purulent. It appeared to me that paracentesis was indicated. I operated-drawing off five and a half litres of thin inodorous pus. I employed Mathieu's double syringe, which enabled me, without removing the instrument, to inject 250 grammes (about half a pint) of a solution of iodine. Decided relief was the immediate result of the operation. The patient said that he breathed freely. He lay on his right side, and went to sleep for some hours. During the night he sweated profusely. Next morning he did not feel so well as in the evening, although the fever had subsided. On the third day after the operation, the 15th November, the pulse was 90, and the skin was warm and moist. On examining the affected part, I found complete dulness in the inferior half, and, on the contrary, above that, there was increased resonance. In that situation, there was neither respiratory murmur, blowing, nor segophony; and there was only to be heard a distant sound of vesicular expansion coming from the other lung. The metallic tinkling and the sound of fluctuation on succussion remained audible; the displacement of the liver continued. Respiration was tolera- bly free when the patient was seated, but it became labored when he lay on the left side. From the 15th to the 20th, nothing noteworthy occurred in his condi- tion ; but on the 20th, the dulness was found to have increased, and to have extended as high up as the third rib. The abnormal amount of resonance, and the stethoscopic signs which I have mentioned, still existed. Above the wound made by the large trocar with which I had operated, the cellular tissue was cedematous, the skin was red, swollen, and painful. During the day, the wound spontaneously re-opened, and discharged about three-quar- ters of a litre of very fetid pus. pleurisy: paracentesis of the chest. 599 Next day, the dulness did not extend so high up, and the exaggerated resonance was heard in the situation which had been previously dull. There was more fever than on the previous days. The patient had a cough which, from its frequency, was fatiguing; the sputa were rusty and very fetid. On the 23d, there was a cessation in the discharge from the fistulous opening in the chest. At that date, I began to hear sounds of respiration behind, at the lower part of the lung, although there was still metallic tinkling. Respiration was freer. There was no fever. On the 25th, the fistula, which had reopened, gave exit to fetid pus, which spurted out with considerable force during the fits of coughing. The physical phenomena observed on auscultation and percussion were dulness and amphoric blowing ; but the visicular murmur was heard over a greater extent, mingled with coarse mucous rales. The general condition of the patient was satisfactory ; and though he ate little, he ate with appetite. From the 25th to the 30th November, there was a purulent discharge from the wound in the chest, which was alternately abundant and scanty; and with these alternations, the extent of the dulness on percussion varied. On the 30th, the resonance was heard as high up in front as the fifth rib, and behind nearly to the angle of the scapula. The vesicular murmur was audible throughout all the upper part. The strength and appetite of the patient were good. He sat up out of bed during the day. From the day of the operation, we had encircled the base of the chest with a girdle made of broad bands of diachylon, which were renewed daily. During the whole of December, the patient made visible progress; but I do not find anything which requires to be specially mentioned. On the 10th January, 1857, the dulness continued as high up behind as the angle of the scapula. The vesicular murmur, still feeble and accom- panied by mucous rales, was heard even down to the bottom of the lung; it was everywhere distinctly heard. The right side of the chest was remarkably constricted. For twenty-four hours, there was not the least exudation from the wound, which seemed to be quite cicatrized. On the 23d January, the patient, who had for some time been on full diet, and eating his entire allowance, asked permission to leave the hospi- tal. He left; retaining no remains of his malady, except a slightly fetid expectoration. He promised to come to show himself from time to time. He came back for this purpose on the 30th: his condition was then excel- lent, although there was still some dulness posteriorly, where the feebleness of the respiratory murmur indicated that all was not yet right. Fifteen days afterwards, on the 13th February, he again returned to see us, when he stated that he had resumed his occupation as a carter. Gentlemen, I have stated that pleurisy, when the effusion has been long present, may become purulent, the pleurisy remaining simple, that is to say, not being the expression of any diathesis, and I have told you, that this is particularly observed in children: I have also remarked, that con- stant determination towards the thoracic organs may lead to the develop- ment of tubercles in predisposed persons. Whenever chronic inflammation is developed without any known cause, or in consequence of a traumatic exciting influence, in individuals under the dominion of the tuberculous diathesis, the manifestations of that diathesis show themselves in the affected organs and tissues. Suppose, for example, a lad, the child of scrofulous parents-a subject in whom there is reason to fear that scrofula exists, though it has never shown itself-suppose that this lad sprain a joint, it is necessary to be very careful, and to watch the injury 600 pleurisy: paracentesis of the chest. much more closely than in an ordinary subject, as there is a risk of the sprain becoming a white swelling: there is a similar danger in respect of abdominal and thoracic inflammations in the scrofulous. In a child of good constitution, born of healthy parents, chronic diarrhoea would not bring with it the same dangers as in strumous or tuberculous children. In strumous and tuberculous subjects, the diarrhoea continues a long time, the intestinal inflammation is persistent, involving the glands of Peyer and the mesenteric glands. You will, under such circumstances, see the affection known by the name of tabes mesenterica [carreau] : or, perhaps, the intes- tinal inflammation, from its contiguity to the peritoneum, will give rise to chronic inflammation of that serous membrane, and to tuberculous granu- lations. Likewise, in persons under the dominion of the strumous diathesis, when a pleuritic effusion is of long standing, the inflammatory determina- tion towards the pleura will call forth manifestations of the diathesis in that serous membrane, precisely as enteritis, peritonitis, and arthritis, are called forth in the mesenteric glands, peritoneum, and joints. From these considerations, then, it follows, that paracentesis of the chest ought to be performed, with the least possible delay, in cases of great pleur- itic effusion. Gentlemen, these extensive pleuritic effusions coming on slowly-these latent pleurisies-are frequently themselves manifestations of the tuberculous diathesis, the expression of incipient phthisis, as was long ago pointed out by Stoll: " Est (pleuritis latens) scepe chronica, non rarb hcereditaria, tumque in phthisin terminanda."* These chronic effusions are not necessarily, as might be supposed, and as has been said, the result of tuberculous inflammation of the pleura, when we find the pleura in such cases coated with characteristic granulations. It is quite true that these appearances are often found ; but it is a question, whether the tuberculous granulations have not been developed consecutively to the effusion. It sometimes happens that these chronic effusions, even when they remain serous and limpid, are the sole thoracic manifestation of the tuberculous diathesis; as is discovered, when patients are carried off by some other affection, and at the autopsy the pulmonary apparatus is found to be perfectly healthy. Here is a case in point: Auguste Thillaye, aged twelve, the son of the keeper of the museum of the Faculty of Medicine of-Paris, a boy of lymphatic constitution, was taken home from school, on account of severe headache and a stitch in the left side above the false ribs. He had no fever. He was put to bed, and the stitch in the side went away: next day, be drove out in a carriage. For several days, he had no appetite; but he made no complaint of pain, and was free from fever and cough. For three successive days, his chest was examined with the greatest pos- sible care, when it was found that he breathed equally well on both sides. Three days later, in the evening, the left side of the chest, from base to summit, was found to be filled with fluid. A blister was applied. Next day, there was fever for the first time. Three days later, the eleventh day from the beginning of the malady, another blister was applied, but with as little success as the first. The effusion increased ; but nevertheless, the child made no complaint of pain. On the 5th I was called in, when I ex- pressed a wish to have Dr. Bouillaud associated with me in consultation. There was great enlargement of the left side of the chest, and the ribs were almost immovable: there was complete dulness, and we heard bronchial * Stoll: Aphorism, 188. PLEURISY: PARACENTESIS OF THE CHEST. 601 blowing and bronchophony. The mediastinum was pushed upwards and to the right, two centimetres from the median line: the heart was pushed over to the right side, and was felt to beat at the right nipple: the liver, and, in a still greater degree, the spleen, were displaced, both descending very low in the abdominal cavity. However, there was very little dysp- noea, but when the patient was agitated, he had some breathlessness; the pulse was 128 and small: the skin was tolerably warm : there were no gas- tric symptoms. I recommended that a third flying blister should be ap- plied ; and that calomel should be administered in small doses with nitrate of potash. For eight days, no amendment was apparent : on the contrary, the pulse became very quick, rising to 144, without any increase in the tem- perature of the skin : the countenance was anxious. A fourth blister was applied. I also prescribed digitalis, which was continued for eight days. The effusion had increased : the heart beat on the right side, beyond and above the right nipple. There was neither orthopnoea, dyspnoea, nor cough. Paracentesis was resolved upon ; and was performed with the usual pre- cautions at 10 in the morning of Thursday the 13th November. Eleven hundred grammes of serosity, greenish, limpid, and very albuminous, flowed from the puncture. Immediate relief was experienced ; but, as almost always happens, the patient had frequent fits of coughing after the opera- tion. The lung at once expanded, and respiration was heard throughout the whole of the lower part of the chest. The heart first came under the sternum, and very soon afterwards assumed its normal position. On the 15th November, the state of the patient was good. Subcrepitant mucous rales were heard through the whole of the front of the chest. On the 24th November, there was a little fever; and some increase in the effusion. The child made a perfect recovery from the pleuritic attack; but he died a few months later of tuberculous meningitis. On making the autopsy, no lesion of the pleura was found, and the lungs appeared to be healthy. There were tuberculous granulations in the brain. This case, then, corroborates the proposition I have just stated, to the effect, that hydrothorax, eveu when the effused fluid is purely serous, may be the manifestation of the tuberculous diathesis. It also shows, that not- withstanding the unfavorable condition of the boy's system, a condition under which he was doomed to succumb ere long, paracentesis, necessitated by the imminence of the danger, was of real utility, for without it, death must have been the inevitable consequence of the pleuritic effusion. When pleuritic effusion accompanies pulmonary manifestations of the tuber- culous diathesis-and then they are generally purulent-paracentesis is useful in those cases in which the largeness of the quantity of the effusion is in itself a formidable complication. Assuredly, the existence of tuber- cles, and still more the existence of pulmonary cavities, leaves but little chance of the operation proving successful ; but if we cannot hope to obtain from it an absolute cure, in consequence of the fatal character of the prin- cipal and dominating malady, we can at least prevent imminent death, and considerably prolong life by performing paracentesis. This was Laennec's opinion.* He said that the bad state of a lung, a lung filled with tuber- cles, ought not absolutely to forbid operating for empyema, not even when pectoriloquy is audible in the summit of the lung compressed by the effu- sion, if the other lung seem to be sound. In such a case, Laennec consid- ered that a cure was possible. * Laennec: Traits de 1'Auscultation Mediate. 2me Edition, t. ii, p. 520. 602 pleurisy: paracentesis of the chest. From cases observed by reliable authors, it appears that paracentesis may even be useful when there is hydropneumothorax. Many years ago, I operated, at an interval of some weeks, upon two individuals who were both patients at the same time in our clinical wards. One of these persons was a Piedmontese, aged twenty-six, who was by profession a juggler. Generally enjoying good health, but from his occu- pation necessarily leading a very irregular sort of life, he attributed the malady for which he sought our aid to a chill got in coming from an even- ing performance. Two months previously, the period to which he referred the beginning of his symptoms, he was tormented by a fatiguing dry cough. He continued, nevertheless, to pursue his ordinary avocations, passing from the coffee-house to the club, and from the club to the drawing-room, going late to bed, eating and drinking as usual, and perhaps to excess. The only measure he adopted with a view to get rid of his catarrh was to take vapor baths and Russian baths. Three weeks prior to his admission to the hospital-that is, three weeks prior to 3d March, 1857-he felt himself worse than usual, but still he did not keep his bed, although he felt exceedingly weak. He was losing his appetite, and after eating, was often seized with fits of coughing followed by vomiting: at night, he was exhausted by profuse perspirations: he was losing flesh: the color of the skin was day by day becoming more and more leaden : at last, he was obliged to give up his occupation, and being at the end of his resources, he resolved to seek admission to the Hdtel-Dieu. When I saw him, he was without fever, but had a wretched appearance, characterized by great paleness, emaciation, and debility. He had hardly any cough, and only a little expectoration, consisting of muco-albuminous matter without any admixture of blood. I remarked that he had the Hip- pocratic deformity of the fingers. On examining the chest, the physical signs of disease were found to be far from proportionate to the almost total absence of the general powers of reaction. On percussion, I found, under the left clavicle, a somewhat di- minished resistance to the finger, and an increase of sound, while on the right side there was nothing abnormal. On auscultation, supplementary respiration was heard on the right side; while on the left, respiration was of a blowing character, and accompanied by vocal resonance. Behind, the resonance was normal in the infraspinous fossa, but it diminished from below the crest of the scapula: from this point downwards, the sound was harsh, and in the lower parts, the harshness became absolute dulness. In the infraspinous fossa, there was double tubal blowing, most decided in ex- piration, during which tubal blowing alone was audible, while during in- spiration, it was accompanied by, and, after fits of coughing, even replaced by puffs of subcrepitant rales. In these situations, the voice was resonant and bronchophonic. On the right side, the respiratory sound was almost normal, except that a blowing sound was heard, which seemed to be pro- duced at a distance from the ear, and which I regarded as transmitted from the left side. These phenomena caused me to hesitate in my diagnosis. The absence of all the symptoms of fever, and the chronic progress of the malady ex- cluded the idea of acute pneumonia : then, in respect of chronic pneumonia, a disease, moreover, very rare, such is not the manner in which it advances nor are its symptoms of this character, as you can ascertain by reading Dr. Raymond's excellent thesis on this affection. On the other hand, while the general symptoms, the emaciation, the loss of strength, the impaired appetite, and the profuse nocturnal perspirations, considered in conjunction with the signs furnished by auscultation and percussion (and which might pleurisy: paracentesis of the chest. 603 depend on cavities) suggested the idea of pulmonary phthisis, I could not harmonize the totality of the signs and symptoms with the extreme scanti- ness of expectoration, and its want of special character, nor with the ab- sence of evident signs of tubercle in the summits of the lungs. I conse- quently came to the conclusion, that the patient presented one of those forms of chronic peurisy in which (as has been very well pointed out by Drs. Rilliet and Barthez) there exists extraordinary vocal resonance, caver- nous respiration, tubal and amphoric blowing, and even gurgling. My colleague Dr. Behier has recently called attention to these facts.* I was thus of opinion that the patient had chronic pleurisy, and I sus- pected, though unable to make good my diagnosis on this point, that there was tubercular deposit on the left side, when-fourteen days after he en- tered our wards-the young man, whose condition had not up to this time indicated any danger, was seized in the morning with acute pain in the left side, dyspnoea, ardent fever, and a slight metallic blowing sound [souffle metallique]. The acute symptoms, the pain at least, abated next day, but the dyspnoea and fever remained. There continued to be almost no expectoration. On this day, we were able to examine the patient more easily than had been possible on the previous evening or during the previous day, from his state of anxiety and restlessness. I detected all the signs of pneumothorax: there was abnormal distension of the chest, increased resonance behind, from the angle of the scapula to the base of the lung, and an absence of thoracic vibrations on the same side. In the infraspinous fossa, there was a metallic blowing sound, which was quite amphoric from the crest of the scapula to the base of the chest: the voice also was amphoric. On apply- ing the ear to the posterior wall of the chest on the affected side, and per- cussing in front, striking a metallic pleximeter with a hammer or a piece of money, a sound was elicited similar to that produced by striking an empty barrel, or still more resembling that caused by striking a bronze vase. This phenomenon was casually pointed out by Laennec; and I have long since called your attention to it. Finally, the apex of the displaced heart was beating below the right nipple. There was no doubt as to the existence of pneumothorax; but the signs of effusion were wanting. It was not till the 8th April-sixteen days later -that I detected them. Day by day, the general symptoms were getting worse. From the 24th March, in addition to the continuance of fever, the excessive restlessness, and the sweating, there was dysenteric diarrhoea, which still farther in- creased the debility. There was still, however, little cough, and the expec- toration continued unimportant in character. Five days later, I distinctly heard Hippocratic fluctuation, when succussion was produced by an assistant, or by the patient himself. The new diagnosis-hydropneumothorax-was therefore distinctly es- tablished. To my great surprise, the general symptoms improved, although the local symptoms continued. On the 29th April, the general state of the patient was apparently satisfactory. But on the 26th May, his condition had again grown worse. Although I thought of practicing paracentesis, the situation of the patient did not seem to me to be so desperate as to constitute an absolute necessity for resorting to this surgical proceeding. Though far from being without anxiety as to the termination of the disease, I was afraid of accelerating a fatal issue by producing within the chest a more violent inflammation than that which already existed there; and * B£hier: Op. cit., p. 611. 604 PLEURISY: PARACENTESIS OF THE CHEST. although I felt certain of not causing death, as that expression is generally understood, I feared that I might occasion its earlier occurrence. Nevertheless, as the patient was growing weaker, as the fever, after temporarily subsiding, had become constant, I thought that it was my duty to try the operation, which (to sum up the argument in a word), however slight a chance it offered, was the only chance left. I resolved then to operate. Believing that I had to do with a purulent effusion, I did not require to give myself any anxiety as to the prevention of air entering the pleural cavity, which moreover already contained air, as the case was one of hydropneumothorax. I consequently operated in accordance with the plan followed by the ancients, that is to say, by making an incision with the bistoury. Having introduced my knife between the seventh and eighth ribs, there gushed along the blade a serous fluid which was slightly turbid, but did not appear to contain pus. I was greatly astonished, for I was expecting to see a purulent fluid: I withdrew the bistoury, that I might introduce an elastic gum sound, and in doing so gave exit to about two litres [more than two quarts] of serosity: I then injected 250 grammes of a solution containing fifty grammes of tincture of iodine and five grammes of the iodide of potassium: I allowed a certain quantity of fluid to flow, after which I closed the wound with large bands of diachylon, of which I made a sort of girdle. The only untoward occurrence to which the opera- tion gave rise was the formation of a serous tumor-a true subcutaneous thrombus-occasioned by the mode of operating which I had adopted: a part of the pleuritic effusion became infiltrated in the subcutaneous cellular tissue, and determined this large thrombus, which had completely disap- peared in forty-eight hours, from the pressure of the bandage which encircled the body. The patient did not complain of pain within the chest, and the symptoms of absorption of iodine were very slight. During the day, he had a decided shivering fit; but in the evening his temperature was not febrile, although his pulse was 120. From the beginning of the pneumothorax, the pulse was 120 (as in other similar cases I have met with), which ought to be attributed to the impediment to the action of the heart, occasioned by the great displacement of that organ. His general condition improved so much, that on the 30th May, he got up, stating that he felt well. His digestion was good, and his bowels regular. Nevertheless, auscultation and percussion furnished the same signs as before the operation. On the 4th June, there was a return of the diarrhoea, fever, and uneasy feelings. On the 7th, I found the expectoration muco-purulent and scanty. On the 22d, the debility was increasing daily: the emaciation was great: and he had some delirium. So great had the debility become, that from this date we were not able to examine the chest, which had presented on previous days, as I have already said, the same phenomena as before the tapping, viz., distension, exaggerated resonance, amphoric blowing, metallic tinkling, Hippocratic fluctuation, amphoric resonance of the voice, and the sound compared to that produced by striking a vase made of bell-metal or an empty cask. From that date, the hectic fever never ceased; and the patient, reduced to a state of extreme emaciation, died in delirium on the 10th July at noon. On that morning, I bad observed in the spittoon bloody, black, frothy, aerated sputa. In other respects, there was nothing particular in the ex- pectoration, which was of the same nature as formerly. On opening the dead body, it was found that the left pleural cavity was coated with thick false membrane, and entirely filled with white, creamy, pleurisy: paracentesis of the chest. 605 inodorous pus. The lung was so closely adherent to the vertebral column, and to the anterior wall of the chest, that it could not be removed without lacerating it; and in consequence of laceration so produced, I was unable to find the orifice of the communication which must have existed between the bronchial tubes and the pleural cavity. The pulmonary tissue was studded with tubercles in various stages: some were hard, but the majority were softening. There were numerous small cavities. The cavity in the right pleura contained about a litre of purulent serosity. The pulmonary parenchyma was riddled with small tubercular excavations. The heart was pushed to the right, beyond the sternum; and the pericar- dium was lined externally with a thick layer of false membrane. Gentlemen, though the.final issue of this case was unfortunate-and the autopsy more than sufficiently explained why it was unfortunate-death could not be attributed to paracentesis of the chest having been performed, as the patient lived six weeks after the operation, which, in place of occa- sioning new symptoms, seemed for a time to produce amendment. The other patient to whom I referred lay in bed 12 of the same ward. He was a man of thirty-six years of age, tall, and apparently of vigorous constitution, who had come to Paris from Berry, where he had had inter- mittent fever. After that illness, in July, 1856, he contracted a pleurisy, which, neglected in the first instance, left behind it a great amount of effu- sion, which occasioned so much oppression that he could neither speak nor drink without being obliged every moment to take breath. Two months later, on the 31st September, he saw a physician, in accordance with whose advice the chest was tapped. More than a litre of very clear water was drawn off. But the effusion was ere long reproduced: on the 25th January, 1857, tapping was a second time resorted to. For two months after the second operation the patient felt well, but the oppression then returned. The least amount of unusual exertion, such as going upstairs, or walking rather quickly, brought on shortness of breath. He experienced a constant feeling of discomfort, and painful feeling of weight on the chest, which was so much increased when he lay on the right side, that that position was impossible. He had had cough from the beginning of his illness. For several days after each tapping, he had an increase of cough, after which, for some time, he had none at all. The cough was accompanied by a very abundant, quite watery expectoration. At one period, when under the influence of the Eaux Bonnes, which he had been recommended to take, there was a mixture of blood-stained sputa in the expectoration, but that entirely ceased when he discontinued the use of the mineral water. He had had a rather profuse dysenteric diarrhoea, which continued from the beginning of the illness, for four months. The inconvenience which he experienced from the oppression of the breathing, and the daily increase of general debility, induced the patient to come to Paris for advice. He entered the Hotel-Dieu on the 9th April. When he presented himself to me he was apparently in a tolerably good state of body. Except a bistre tint of countenance, which recalled the aspect of those who have lived in an atmosphere contaminated by marsh miasmata, his general state seemed satisfactory. Upon examining his chest, to which he at once called my attention, I ascertained the following facts. The left side of the chest was decidedly dilated. On percussion, the right side everywhere yielded normal reso- nance, except at a distance of two finger-breadths within the nipple, where there was dulness in a space of two or three centimetres from above down- wards, and which, limited transversely outwards at the point I have stated, 606 pleurisy: paracentesis of the chest. became confounded internally with the dulness of the left side. On the right side the respiration was puerile, and exaggerated, without rales. On the left side, in front, the body being in a horizontal position, the sound elicited was clear, from the clavicle to the nipple: but in proportion to the extent to which the trunk was raised, percussion yielded complete dulness, and when he was quite in the sitting position, the dulness extended as high up as the third intercostal space. Behind, there was complete dul- ness in the whole of the lower part of the chest, from the spine to the scap- ula downwards. On auscultation the vesicular murmur was very faintly heard under the clavicle and in the infraspinous fossa, and was inaudible lower down: the cough had an amphoric resonance. During inspiration there was also heard amphoric blowing. Finally, by an assistant percussing in front, while the ear of the observer was placed on the opposite wall of the chest, an exceed- ingly well-marked bell-metal sound [Snzzt d'airairi] was heard. Succussion produced the sound of fluctuation [bruit deflof]; and this was also audible when the patient shook himself moderately. This bruit de flot was heard at a certain distance, a fact of which the patient was perfectly aware. From 9th April to 28th May, nothing worthy of being mentioned oc- curred. The cough was moderate, and the expectoration was mucous, de- void of any special characteristic. There was no change in the general state of the patient. He never had any fever: the pulse was small, and, it is true, beat 100 in the minute, but as its feebleness and quickness were not accompanied by heat of skin, they were no doubt dependent upon the im- pediment to the action of the heart occasioned by that organ being firmly pushed over to the right, where its apex was beating in the space where the dulness was observed at twice the breadth of a finger to the inside of the right nipple. Evidently, hydropneumothorax existed in that situation. Every day the patient besought me to relieve his difficulty of breathing. I consequently resolved to perform paracentesis, and to follow it up by in- jections of a solution of iodine. This, in fact, was the treatment which originally suggested itself to me in this case when the patient came into my wards; but I did not then operate, as I thought that, upon the whole, the case was not very urgent, and that the operation might disturb the general state of the system, which was in an apparently satisfactory condition. However, taking into account this satisfactory state of the general system, considering the entreaties of the patient, encouraged, moreover, by the cases of cure of hydrothorax of which I have already spoken, I made up my mind : and on the 28th May I performed paracentesis. I made an opening into the chest, by an incision of a centimetre in breadth, in the intercostal space between the seventh and eighth ribs. A purulent fluid spurted out, mingled with gas, which escaped with a bubbling sound. About 150 grammes [19 ounces] of thin inodorous pus were with- drawn. Immediately after the tapping I introduced into the wound a bent silver canula fitted with a stop-cock, and having a thin piece of caoutchouc so adjusted as to protect the integuments, and keep them from being excori- ated by contact with the metallic beak. Having emptied the pleural cavity, I passed into the canula now described a gum elastic catheter, through which I injected a mixture of 50 grammes of the [French] tincture of iodine and 5 grammes of iodide of potassium, dissolved in from 100 to 120 grammes of water. I then withdrew the elastic instrument, leaving in the chest nearly half of the injected fluid; and shutting the stop-cock of my canula, I fixed the apparatus in its proper place, by means of a diachylon bandage. PLEURISY: PARACENTESIS OF THE CHEST. 607 The only accident which resulted from the operation was slight subcuta- neous emphysema, which disappeared in a few days. The patient, who was at first a good deal agitated by the operation, assured me when it was over, that it had not occasioned any pain. In the evening, he complained of pain at a point corresponding to the wound made in performing the para- centesis; but he had no fever, and the pulse had even come down to 76. The heart was nearer its normal position, its pulsations being felt under' the right edge of the sternum. Next day, I withdrew from the chest a litre and a half of fluid, consist- ing of pus mixed with the iodine injection: it spurted out in jets with the pressure exerted upon it by the cough, which came on involuntarily. On 30th May, a second injection, similar to the first, was thrown into the pleural cavity, after I had evacuated by the wound about a litre of puru- lent fluid containing some sanguinolent striae. The injection was repeated on the 2d and 4th June. The general state of the patient continued good, and from day to day the flattening of the thorax proceeded: from day to day, also, less fluid was withdrawn when the canula was opened : a certain quantity escaped during the 24 hours, running down the walls of the chest: but on the 6th June, only a few spoonfuls were collected. The fluid preserved its purulent char- acter, and remained inodorous : on that day, the fifth, and a few days later, the sixth injection was made. These injections were repeated every three or four days, up to the 28th July, at which date the seventeenth injection was performed. The patient suffered no inconvenience from the injections except a sensation of heat in the chest. The only symptoms of iodism which he presented was a certain amount of itching, and, on one occasion, the taste of iodine in the throat. The chest became more and more flattened ; but the signs on ausculta- tion remained nearly the same, till the 12th June. On that day, I heard, under the left clavicle, some rather coarse mucous rales which were not dis- placed, but rather increased, by coughing. The effusion was really dimin- ished, but the capacity of the thorax was lessened by the great flattening of its walls which had taken place, while the heart, gradually reoccupying its normal position, was now beating on the left side, its apex still remain- ing, it is true, three finger-breadths to the inside of the left nipple. On the 17th June, an instrument made of gum was substituted for the silver canula. On the 25th June, the gum sound was finally removed, as the wound re- mained sufficiently open to allow an instrument to be introduced when an injection bad to be made. A remarkable auscultatory phenomenon was present, a phenomenon to which I have often called your attention. This was a sound heard pos- teriorly over the infraspinous fossa, a blowing sound, so soft and so velvety [tellement en nappe], if I may venture to use such an expression, that it might be mistaken for the normal respiratory murmur; it was not, how- ever, exactly the vesicular murmur; and in this situation there was exag- gerated thoracic resonance. The general condition of the patient presented alternations of amend- ment and retrogression. On the 12th June he was seized with diarrhoea, which continued for a fortnight to resist treatment with chalk, bismuth, and nitrate of silver, but which at last yielded to a pill taken twice a day, consisting of 005 of ipecacuan, 0.005 of extract of opium, and 001 of calomel.* Though the diarrhoea reduced his strength, be retained his * Five centigrammes (005) is about five-sevenths of a grain ; and one centigramme (001) is about one-seventh of a grain. Five milligrammes (0.005) is about five- seventieths of a grain. 608 pleurisy: paracentesis of the chest. appetite. Under the use of cinchona wine and a tonic regimen, he regained strength. On the 28th July, enchanted with his condition, he was boast- ing of ascending the stairs of the hospital without experiencing fatigue, or being much winded. Somewhat copious perspirations, the occurrence of which was coincident with the diarrhoea, were now less considerable. The amendment, nevertheless, did not continue; and I was obliged, at intervals, to return to the use of the iodine injections, which were in all em- ployed forty-two times. In the beginning of the following year he became the subject of hectic fever, by which he was carried off' on the 28th Feb- ruary. At the autopsy, w'e found tubercles in the lungs. In 1853, I submitted the history of a similar case to my colleagues of the Medical Society of the Hospitals. The patient was a woman aged 3-1, who when she came into my wards had all the signs of hydropneumothorax: the oppression in the breathing was so great that death seemed imminent. I performed the operation by incision for empyema. As in the first of the two cases which I have now narrated to you, the fluid removed was limpid and transparent, and the gases were perfectly inodorous; but on the third day after the operation the fluid had become fetid : I then injected a solu- tion of iodine, which occasioned neither pain nor feverish reaction. Seven days later, erysipelas supervened at the base of the chest, under the dia- chylon bandage which had been applied. I nevertheless repeated the injection, using, however, a weaker solution : in the evening, some symp- toms of the toxic action of iodine showed themselves. The erysipelas progressed, and invaded the edges of the wound. Fifteen days after the tapping, the patient died. At the autopsy, the pleura was found coated with a layer of pultaceous purulent matter, which was easily scraped off with the back of the scalpel. The lung was so shrunken as not to occupy more than the two upper thirds of the vertebral hollow. We found the perforation. There were tubercles in this lung; and in its centre, cavities which contained neither pus nor blood. The paracentesis cannot be considered as having been the cause of death in these two cases, any more than in the first which I described: in both the men, who were patients in St. Agnes's Ward, death occurred at a long interval after the operation, and in the woman of St. Bernard's Ward, the erysipelas of the trunk having begun in a situation remote from the trocar- wound, was a complication independent of that wound. Moreover, in the last-mentioned case, paracentesis was the only possible means of prevent- ing death, which the impediment to respiration rendered imminent. Hence, gentlemen, in hydropneumothorax, even when associated with tubercles in the lungs, the practitioner ought to intervene surgically, if the evolution of gas and the effusion of fluid threaten to produce suffocation. Some physicians who deny the utility and necessity of tapping the chest in cases of excessive effusion, simple or purulent, say that the operation proves beneficial when the hydrothorax is complicated with bronchial fistula. This, you observe, is to go far beyond what I teach; for while I hold that paracentesis is necessary in cases in which there is a large quantity of effusion without any complication-while I consider that it is useful in such circumstances, especially in children, in whom the effusion is apt to be purulent, I make reservations in respect of hydropneumothorax, particu- larly when it is symptomatic of pulmonary tubercle. When the question of performing paracentesis arises in such cases, I hesitate very much to operate; but I grant that even in such cases, though tapping does not cure, it gives great relief and prolongs life. Dr. Hughes, physician to Guy's Hospital, London, mentions a case in pleurisy: paracentesis of the chest. 609 which he accomplished a cure after two tappings. The patient having succumbed long afterwards under the progress of the tuberculous disease, which showed itself in the other lung, it was observed at the autopsy that cicatrization had taken place on the side first affected. Cancer of the pleura may be accompanied by effusion in such quantity as to necessitate paracentesis. I need not tell you that we possess no positive sign by which to recognize during life the cancerous nature of the pleurisy in such cases. However, if in a woman affected with cancer, or particularly in one from whom a cancerous tumor has been removed, we meet with pleural effusion slowly developing itself, we may conclude that the bronchial glands and the pleura are themselves the seat of cancerous disease: the nature of the fluid withdrawn at the time of operation by the trocar will have a great significance. In July, 1860, my friend and colleague Dr. Barth showed me a bottle containing a certain quantity of bloody fluid which he had drawn off from the chest of a patient, who had excessive pleuritic effusion. At first he was alarmed: it was not till he had reassured himself by reflecting upon the very great care with which he had examined the case, and formed his diagnosis prior to the operation, that he could divest himself of the idea of having penetrated an aneurism. I at once said to him, that he would most probably find at the autopsy a cancerous pleurisy. And it was so: there was found cancer of the lung and pleura. The only credit I deserved for this diagnosis was recollecting to have seen in my wards at the Necker Hospital, in 1844, a case of the same description-a case which I shall now relate to you. On the 9th November, 1844, a woman, aged 54, suffering from cancer- ous atrophy of the right breast, became my patient in the Necker Hospital. She had been several months in the Saint Louis Hospital for rheumatic pains of the limbs, unaccompanied by any general disturbance of the system. She had some vapor baths. One day, about the 20th November, when returning from the hot-room, she felt a chill, and was attacked by an acute pleurisy on the right side, which presented nothing special *i its symptoms. It was treated by bleeding, blistering, digitalis, and calomel. About the 20th December, the effusion, so far from diminishing, was increasing. There was at that date only a very moderate degree of fever remaining. Three issues were placed on the chest. The effusion continued to increase to such an extent, that, by the end of December, it had reached the clavicle and the infraspinous fossa of the scapula. By the beginning of January, 1845, the distension of the chest had become evident: in front, the dulness soon passed the median line, and the heart was a little thrown to the left: by the 20th of that month, the dulness had passed four centimetres beyond the median line, and the heart was still more thrown out of its place : the liver was pressed down into the abdomen, and could be felt far below the false ribs. Notwithstanding this state of matters, the patient had no dyspnoea, except sometimes a little orthopnoea in the even- ing. There was decided fever. I perceived puffiness of the face, and infil- tration of the abdominal parietes. On the 24th January, paracentesis seemed to be urgently necessary; and was then performed, in accordance with the customary rules. During the flow of the serosity, which was bloody, no coughing fits occurred. The amelioration which followed the operation was very slight: the stethoscopic signs remained unchanged. From the 1st to the 11th February, the state of the patient was nearly stationary ; but at the latter date, erysipelas set in, having as its starting- vol. i.-39 610 PLEURISY: PARACENTESIS OF THE CHEST. point one of the issues on the chest. Noth withstanding these occurrences, the effusion having made additional progress, and threatening to suffocate the patient, I again performed paracentesis: again, I obtained a sero-san- guineous fluid. The dropsy of the chest increased, the strength failed, and soon afterwards, the woman died. At the autopsy, I found the pleura cancerous, and covered, throughout its entire extent, with encephaloid growths. You will find in the thesis of Dr. Lacaze du Thiers a case identical with that now described. It was observed in 1850 by Dr. Lemaitre in Professor Andral's wards: the subject was an old man. At the autopsy, cancer of the pleura and cancerous tumors in different parts of the body were dis- covered. Gentlemen, changes analogous to those which take place in the pleura occur in the peritoneum. Recall to your recollection two women suffering from ascites, in whom I performed abdominal paracentesis in 1860. The effusion prevented me from recognizing the presence of any tumor. From the time that the fluid began to flow from the canula, I told you that there was cancer of the peritoneum ; and the autopsy, made soon afterwards, showed me that I was not mistaken. The fluid drawn off was bloody. I also intimated that, in accordance with the law established by Dr. Barth, we should find some of the abdominal viscera affected with cancer; and at the autopsy, this diagnosis was verified. But, gentlemen, let me impress on you the fact, that to cause excessive pleuritic effusions to be bloody, it is not enough that cancerous productions should be disseminated in different parts of the body-to produce that result, the serous membrane itself must be affected with cancer. In 1849, I received as a patient at the Hospital for Children, a male child eight years old, whose history is given at page 71 of the thesis of Dr. Lacaze du Thiers. This child had extensive effusion on the left side of the chest: for this affection I performed paracentesis, drawing off'an amber- colored fluid. Recovery from the pleurisy took place: but after languish- ing for some time, the child sunk under epileptiform convulsions, which continued for two days. A$ the autopsy, small apoplectic clots were found in the brain. The kidneys, peritoneum, anterior mediastinum, pericardium, and the heart itself were invaded by cancerous products: but there was no cancerous disease of the pleura. But, gentlemen, the existence of a sero-sanguineous effusion does not afford absolute proof that there is cancer of the pleura or peritoneum. At the 57th page of the thesis of Dr. Lacaze du Thiers, you will find an account of a case observed by Dr. Tardieu which will prove to you that the pleura, even though not cancerous, may yield a bloody serosity. Dr. Aran commu- nicated to me a case of the same description; and similar cases are reported by the illustrious author of the Treatise on Mediate Auscultation. In a memorable discussion which took place in the Medical Society of the Hospitals of Paris in relation to Dr. Barth's case of which I have just been speaking, Professor Natalis Guillot referred to the history of an epidemic of measles, during which he had seen several children die of hemorrhagic pleurisy. On the same occasion, Legroux mentioned two cases in which he had found sero-sanguineous effusion into the pleura, irrespec- tive altogether of any cancerous diathesis. It still remains for me to develop another reason-as appears to me- for resorting to paracentesis of the chest in cases of extreme effusion. In proportion to its duration, pleurisy becomes less and less curable, from the lung pleurisy: paracentesis of the chest. 611 attracting adhesions which prevent it from regaining its place in the thoracic cavity and fulfilling its functions. In pleuritic effusions of long duration, the false membranes, at first albumino-fibrous, then fibro-cartilaginous, intimately soldered to each other by a cellular tissue, the product of a secondary inflammation, fix the lung to the vertebral column at the points towards which the effused fluid has pushed it. It then resists the efforts of the external air, which in the normal state contends against the natural elasticity of the organ, and tends to dilate its tissue. The lung being thus fixed, is no longer able to fill the cavity of the thorax, and that cavity is consequently narrowed and con- tracted by the pressure exerted on its walls by the external air. Contraction of the chest consequent on pleurisy is a subject to which Laennec directed the special attention of physicians; and all of you are no doubt acquainted with the article which he has devoted to it in his chapter on pleurisy. He has pointed out, in a very remarkable manner, the cir- cumstances under which this contraction takes place; and has described the anatomical state of the lung, which is so compressed and flabby as to resemble muscle, the fibres of which are so fine as to be undistinguishable. He has indicated, in a not less able manner, the signs furnished in these cases by auscultation and percussion. He then adds " that the contraction of the chest may be regarded as a real cure, inasmuch as even when it pro- ceeds to a high degree, it not only does not render the person in whom it occurs a valetudinarian, but may even be associated with a certain amount of general vigor. Moreover, in his opinion, it does not leave any cause of a relapse, for if pleurisy is observed very seldom in cases in which the costal and pulmonary pleura are united by a great amount of cellular tissue, it ought to be regarded as impossible when the union takes place by means of a tissue so little disposed to inflammation as fibro-cartilaginous tissue." There can be no doubt that contraction of the chest is one of the ways in which a cure is accomplished; but this mode of cure sometimes leads to incurable deformity of the chest, at least in adults: in children and young men the deformity generally decreases and ultimately quite disappears. This'kind of deformity has been admirably described by Laennec. " The subjects," he said, " have the appearance of being bent upon the affected side, even when they try to keep themselves erect. The affected side of the chest is evidently narrower: on measuring it with a cord, a dif- ference of more than an inch is often found between it and the sound side. Its breadth is also diminished : the ribs are in closer than normal proximity to each other: the muscles, particularly the pectoralis major, are only one half the size of those of the opposite side. The difference between the two sides it so striking, that at a first glance one would suppose that it is much greater than it is found to be on measuring. The vertebral column gener- ally retains its straightness; but sometimes, however, it deviates a little, in consequence of the patient always leaning towards the affected side. This habit imparts to the mode of walking a peculiarity somewhat similar to limping." This is not all: a long time elapses before the cure is complete: between the lung fixed to the vertebral column and the thoracic walls, there is a free space into which there is an interminable succession of effusions. Para- centesis prevents this; for by rapidly evacuating the serosity, it allows the lung to reassume its place almost immediately, and consequently before there has been sufficient time for adhesions to form. 612 PLEURISY: PARACENTESIS OF THE CHEST. The Quantity of the Effusion regulates the time at which Paracentesis is indi- cated.- The General Symptoms and Oppression of Breathing are Falla- cious Indications.-The only Trustworthy Signs are those furnished by Auscultation and Percussion.- The Manner of Operating.- Certain Phenomena which supervene during the Flow of the Fluid.-Coughing Fits.-Flow of blood from the Wound,- The Serosity jellies in cooling, and sometimes assumes a rosy color.- Circumscribed Pleurisies.- Objec- tions to Paracentesis.-Paracentesis in Empyema.-Injections of Iodine; and the Permanent Canula. Gentlemen : I have stated the reasons which render paracentesis of the chest a necessary operation : I have told you the accidents which it may prevent, and the circumstances in which it is applicable. I ought now to set forth the indications for resorting to it. When the accidents of which I have spoken, when the fainting fits and the lipothymia recur, when suffocative paroxysms show themselves, surgical intervention is urgently required; for then nothing but paracentesis can avert death. I have already supported this proposition by citing a certain number of cases. Here is another to which I beg your attention. Dr. D., a physician, aged 35, who never had had any pulmonary affec- tion, begun in August, 1848, to experience difficulty in breathing, accelera- tion of pulse, and general debility. During the night, the heart beat most quickly; and dorsal decubitus was painful. Matters continued in this state for a month. My honorable colleague Professor Andral having been consulted, detected thoracic effusion, and attributed it to a chronic pleurisy which had passed unnoticed. He recommended a large blister to be applied. On the 13th October, Dr. D., after exposure to severe cold, was attacked by acute pleurisy on the left side. During the following days, he was three times copiously bled ; and on the 25th, Dr. Andral again recommended the application of a large blister. When I was called in, the symptoms had become anxiously severe. The patient was having fainting fits; his features were distorted; and his debility was extreme. The skin was pale and cyanosed. The countenance expressed anxiety. There was considera- ble dyspnoea, and the respirations were 30 in the minute. The pulse was 115, and irregular. I found complete dulness of the whole of the left side. The mediastinum and heart were pushed to the right. Such being the state of the case, delay was impossible, and paracentesis was immediately performed. The operation afforded an exit to four litres of yellow, limpid serosity. I shall afterwards return to this case, and give you some interesting additional particulars regarding it. In the meantime, I may add that convalescence was rather protracted-that ou the 2d December, the patient began to get up, and wished at once to resume his practice, but he found himself obliged to discontinue making visits in consequence of the suffoca- tive fits which he experienced. He went to the neighborhood of Dieppe, where, by the use of horse exercise, he regained strength and health. From the 1st June, Dr. D., considered himself as cured: but his chest was con- tracted on the left side, and continued to present dulness on percussion, and obscurity in the respiratory murmur. At that date, these phenomena were perhaps more marked than they were an hour after' the operation, eight months previously. Some months later, however, he felt no remaining trace of the malady, and even the deformity of the chest had disappeared. At present, Dr. D. enjoys the best possible health. Gentlemen, under circumstances similar to those which presented them- pleurisy: paracentesis of the chest. 613 selves in the case now described, it is impossible to hesitate ; and no one will deny the absolute necessity of evacuating the effused fluid which is the cause of all the complications. But in addition to these cases, whenever the signs furnished by auscul- tation and percussion reveal the presence of an extensive pleuritic effusion which may be estimated at about two litres-whenever an effusion of this description, irrespective of its nature, supervenes without very marked local phenomena, without decided symptoms of reaction, it will augment rapidly-when, after a certain time, nine or ten days, for example, the disease has been combated more or less energetically by the ordinary thera- peutic measures, and the effusion has nevertheless notably increased in quantity, the indications seem to me decisive, that the chest ought to be tapped. When the pleural cavity is not quite full, though the operation may be free from objection, and in fact offer advantages, its performance may be delayed for one or two or even for four days, always taking care, how- ever, closely to watch the patient. In such cases, it has happened, as I have seen, that spontaneous absorption has taken place of extensive effu- sions, for which it had seemed that surgical interference would ultimately be necessary. But paracentesis ought to be performed with the least possible delay, when the effusion completely fills the serous cavity, a condition indicated by absolute dulness on percussion, extending from the base of the chest in front to the clavicle, and behind, to the top of the infraspinous fossa of the scapula, forcing out of their places diaphragm, liver, spleen, and heart. The complications which I have just been mentioning are of a threatening character. I certainly cannot affirm that death would necessarily be the immediate consequence of this excessive effusion ; but it would be impossible for me to repeat too often that there are cases of this kind, in which an unfavor- able issue has been the result of delaying surgical interference, and that these cases are sufficiently numerous to warrant the clinical physician to perform an operation which is not dangerous in any circumstances. Grant that the patients do not die suddenly, they will be exposed to consecutive dangers regarding which I have already spoken so fully, that it seems unnecessary to return to that subject. One might be tempted to believe that there is no positive indication to perform paracentesis, except when the individual who had pleuritic effusion suffers from great oppression in the breathing; that there is no urgent necessity for operating, unless suffocation is imminent. Gentlemen, that is a serious mistake against which I must warn you. Oppression is one of the most deceitful of signs ; and in speaking to you of the young woman who has furnished the text for the present lecture, I have called your attention to this cardinal point. It is, however, a point of so much clini- cal importance, that I do not scruple again to insist upon it. There are patients who, from the very beginning of the pleuritic attack, when there are hardly a few spoonfuls of fluid effused into the pleura, experience great oppression, which goes on diminishing as the effusion increases. There are others, again, in whom oppression does not super- vene till the amount of effusion has become considerable, and which in- creases with the amount of the effusion. There are others, also, who, though they have become almost suddenly affected with a great amount of hydrothorax, have never complained of the least embarrassment in respira- tion. It was so in the case of the woman who occupied bed 12 of St. Ber- 614 pleurisy: paracentesis of the chest. nard's Ward ; and so it was also in the case of the man who lay in bed 19 of St. Agnes's Ward. The latter was a strong and vigorous individual, a worker in lead, who, when admitted as a patient at the Hotel-Dieu, was complaining of colic. I then observed in the edges of the gums a bluish line, which seemed clearly to show that he.was suffering from saturnine symptoms. He lay on his back, and did not seem to experience the slightest degree of oppres- sion. On feeling the abdomen with the hand, I detected in the right side a movable tumor, which descended as low down as the iliac fossa. At first, I supposed that it was composed of an accumulation of fecal matter in the colon. The patient made no complaint of any thoracic symptoms. On examining the chest, however, I was surprised to find, on percussion, complete dulness from the base to the top of the left lung, even up to the clavicle and to the summit of the infraspinous fossa of the scapula. The heart was squeezed to the right, and was beating beyond the sternum, even under the right nipple: the abdominal tumor was the pressed down spleen. I heard no respiratory sound. There was, therefore, nothing in the case to lead one to suspect the pres- ence of the enormous effusion which existed, except the physical signs fur- nished by auscultation and percussion. Although the man did not seem at all inconvenienced, I thought it necessary to perform paracentesis : and I operated next morning. I withdrew more than 3500 grammes [upwards of 3] quarts] of serosity, perfectly limpid and yellowish. In endeavoring to elucidate the previous history of the case, I ascertained that the effusion had begun six weeks, or two months previously. The patient recollected that he had had a chill at that period : he also remembered to have then had a slight stitch in the side, and some cough : but these symptoms did not prevent him from continuing his usual routine. In this case, recovery took place rapidly; and some days after the operation the patient left the hospital. Some time afterwards, my chef de clinique, Dr. Moynier, had occasion to tap the chest of a lad of thirteen and a half years of age, who, though he had more than two litres of serious fluid effused into the pleural cavity, did not appear to be embarrassed in his breathing. At the beginning of April, this lad had suffered in health from hard work. The sanitary derangement consisted in a gastric affection, which yielded to rest and a purgative. Recovery, however, was not complete: the patient retained slight feelings of discomfort, and had not his usual vivacity. On the 22d April, he took cold from remaining inactive in a room on the ground floor; and in the evening, he had an attack of rigors, which was repeated on two successive days. He, at the same time, felt a pain in the right side of the chest, which afterwards affected also the left side going up as high as the shoulder. He had fits of coughing, unaccompa- nied by expectoration. He nevertheless continued his habitual occupations, doing everything as usual, assisting his mother in the household work, and having his ordinary appetite. So little did he feel any difficulty in breathing, that on the 1st May, he carried two pails of water up to the fourth floor of the house, and six days later he walked to the Madeleine and back to his residence in the Rue Lafayette. On the 7th May-the day after this walk-he consulted Dr. Burq. He then complained of having had little inclination for food for four or five days. He was distressed by fits of coughing, which had latterly been more pleurisy: paracentesis of the chest. 615 frequent, and by transient attacks of fever coming on in the evening, which, when over, allowed him to sleep quietly all night. Dr. Burq having discovered that there was a large amount of effusion on the left side of the chest, brought the patient to me. I perceived consider- able arching of the walls of the chest. The ribs were raised up, and the intercostal spaces were flattened. There was an absence of thoracic vibra- tion ; behind, absolute dulness existed from the base of the chest up to the infraspinous fossa, and in front up to the clavicle: no respiratory sound could be heard. On the right side, the vesicular murmur was exaggerated. The apex of the heart was felt to beat below and to the outside of the right mamma. Tapping appeared to me not only to be indicated, but to be urgently re- quired. I sent the lad to Dr. Moynier, who wished to be intrusted with the operation. Two litres of lemon-yellow serosity flowed from the canula. As generally happens-as I shall afterwards have to tell you-whilst the chest was being emptied, the patient was seized with constant fits of cough: towards the end of the evacuation, the fluid changed its character, first be- coming tinged with blood, and then becoming quite bloody. This is an occurrence which I shall have to point out to you, when speaking of the phenomena which accompany paracentesis. Proportionally as the fluid flowed from the chest, the heart resumed its place below the left mamma: sound on percussion, and also the vesicular murmur, returned to the affected side. After the operation, he had a ten- dency to syncope : and till the evening, he had a succession of coughing fits. Next day, the state of the patient was satisfactory : there was still a little dulness in the lower part of the left side of the chest; and on that side, res- piration was feeble. In seven days, recovery was complete. To sum up: When the oppression is a sign in addition to the physical signs furnished by auscultation and percussion, it has an important signifi- cation ; but its absence ought not to inspire too great a feeling of security ; for by refraining from interference, we run the risk of losing patients whom the operation would assuredly have saved. It is from auscultation, and still more from percussion, that we must derive our most positive indications as to the opportune moment for performing paracentesis of the chest. Gentlemen, I now come to speak of what pertains to the operation itself. In consideration of the details into which I entered when tracing the history of the question, I need now give only a very brief account of the mode of operating. Given-an acute pleuritic effusion, for which it has been decided to operate: How ought paracentesis to be performed? I have already told you, that for a long time a very exaggerated idea was entertained of the danger of allowing air to enter the pleural cavity. It was at one time supposed that the entrance of a few bubbles of air into the chest would be sufficient to cause death, the notion being that the con- tact of the effused fluid with the atmospheric air would lead to a sort of putrid fermentation. I told you that surgeons, with a view to prevent this danger, had invented different apparatuses; and in particular I spoke to you of the instrument of Schuh. The instrument contrived by Recamier, constructed on Schuh's principle, is also upon the plan of having a valve adapted to the beak of the canula of the trocar. This valve, kept in its place by the pressure of a spring, and covered with a bit of leather, exactly resembling the key of a flute, is accurately applied to the orifice of the instrument, and can only be raised by pressure from within proceeding outwards. Ingenious though this apparatus was, much less complicated 616 PLEURISY: PARACENTESIS OF THE CHEST. though it was than Schuh's instrument, it nevertheless presented inconve- niences, not the least of which was its not being within the reach of all practitioners. The apparatus of M. Reybard, from its extreme simplicity, offered every advantage: I have explained to you this apparatus: it is that which you have seen me use, and which is employed at the present day by all operators. Let me remark, however, that in the cases in which M. Reybard believed it to be useful, I generally do without it. It was especially for the evacua- tion of purulent accumulations that the surgeon of Lyons considered para- centesis of the chest necessary. In such cases, the introduction of air into the pleural cavity is an almost inevitable occurrence, and one moreover regarding which no anxiety need be entertained ; because in the treatment of empyema, the canula is sometimes allowed to remain in the chest, and because in any case a fistula is formed, which establishes a communication between the pleural cavity and the external air. When the effusion is serous, M. Reybard's canula is unquestionably use- ful : in such cases, indeed, it is indispensable. I am speaking, observe, of M. Reybard's canula, and not of his method of operating; for the latter is far from presenting the same simplicity as the former. Here is his opera- tion as described by himself in his memoir published in the Gazette Medi- cale for the 16th and 25th January, 1841: The chest is penetrated, either through an intercostal space, by an incision with a bistoury, or by boring a hole in one of the ribs by a gimlet, a very old practice which, according to M. Reybard, affords great facility for more securely fixing the canula, when it has to remain in its place for a long time. The incision in the soft parts ought to be very free, but it is specially important to make the open- ing in the pleura no larger than is necessary for the admission of the canula. As soon as the opening has been made, both lips of the wound in the skin have to be seized between the thumb and index finger of the left hand, while with the right hand, the operator introduces the trocar armed with a piece of sticking-plaster. All these proceedings were necessary, in the opinion of the surgeon of Lyons, to prevent the entrance of air into the pleural cavity. He also gives a caution not to push in the instrument too far, lest the lung be grazed ; and to protect the lung from being wounded, he says that the extremity of the canula ought to be rounded. Such is the operative proceeding recommended by M. Reybard in cases of empyema-in cases in which there is a collection of pus. If it be a fact that one can dispense with taking so much precaution, this mode of oper- ating is not only useless but exceedingly dangerous in cases of simple pleu- ritic effusion, for it involves the risk of transforming the simple pleurisy into hydropneumothorax and empyema. In point of fact, gentlemen, ere the canula has been twenty-four hours in the wound, it has acted as a foreign body, producing inflammation of the skin, cellular tissue, and pleura, in the neighborhood of the opening made for it: moreover, during the efforts of inspiration and expiration, notwithstanding every care taken to prevent it, the air. pressing along the sides of the canula, enters the pleural cavity: scarcely have a few days elapsed, when it is found that there is hydropneumothorax, and that the serous fluid in the pleura re- cently so limpid, has become fetid and purulent. It was to avoid in part this inconvenience, that M. Reybard tried to restore to favor the plan of perforating a rib: but he did not avert-he only retarded the danger. The method of operating which I have recommended, and which is now univer- sally adopted, besides being simple, is free from danger. The only instruments which are indispensable are in the hands of all medical men ; viz., a bistoury, or better still a lancet, which is much less pleurisy: paracentesis of the chest. 617 alarming to the patient, to make the little incision, which need only involve the skin-and a common trocar such as is used in puncturing the abdomen, or a hydrocele. The lips of the trocar are surrounded with gold-beater's skin, which is softened by being wetted. When gold-beater's skin cannot be obtained, a piece of the intestine of a fowl, rabbit, or cat, a bit of blad- der, or a condom will serve the purpose. After tying the membranous tube to the instrument, by means of a thread, a trial is made of the work- ing powers of this sort of valve by drawing in and blowing out alternately through the extremity of the canula opposite that which has the lips. Finally, there is required a piece of English court-plaster, or diachylon plaster, cut in the form of a Maltese cross, wherewith to close the wound after the operation. At present there is a discussion as to the particular point where the punc- ture ought to be made. The question is- What is the preferable place for performing paracentesis of the chest ? The place which I select is (counting from above downwards) the sixth or seventh intercostal space, nearly four or five centimetres external to the outer edge of the pectoralis major. The patient being placed in a half-sitting position on the edge of his bed, the trunk supported by pillows, an assistant is intrusted with supporting the opposite side of the chest in such a way as to resist the involuntary recoil of the patient, which is apt to occur as the trocar penetrates the pleura. With the left hand the operator renders the skin very tense, and then, with the lancet held in the right hand, he makes a puncture in the skin-only in the skin-no larger than is requisite for the admission of the trocar. This preliminary puncture is necessary; for in this respect thoracic is different from abdominal paracentesis. In the latter there is no objection to making the perforation by one act, because the abdominal walls are wholly composed of soft parts; but in paracentesis of the chest it is essential to facilitate the introduction of the instrument in the manner I have now described, other- wise you may incur the risk of striking the ribs with the trocar, from the patient, influenced by the painful sudden contact of the instrument, curving the chest inwards, and so diminishing the extent of the intercostal spaces by approximating the ribs. There is no risk of this occurring if the preliminary penetration of the skin be accomplished in the manner I have pointed out. When the skin has been penetrated, you introduce the point of the trocar within the little wound, and then, with a bloodless push, you easily get the instrument through the muscles and into the thoracic cavity. Formerly I used to recommend another manoeuvre, which, latterly, I have felt to be quite superfluous. With the view of avoiding every chance of the introduction of air into the chest, I believed that it was necessary that the external and internal openings should not be parallel. To accom- plish this object, I punctured the skin below the intercostal space through which I had to penetrate, and then forcibly drew the skin upwards, so as to make my little wound in the skin correspond with the intercostal space. As soon as the operation was completed, the parts resumed their natural position, the parallelism between the two openings ceasing. But long ago I perceived that these precautions were unnecessary: the parallelism is naturally destroyed by a mechanism which is easily understood. When the chest is distended by a great quantity of fluid, the ribs and intercostal spaces are in the same position in which they are placed by a forced inspi- ration, and have necessarily the relative situation which they have to the internal integument when in a state of repose: their play is under the skin, which does not follow their movements. Consequently, after the puncture, and after the evacuation of the fluid, the chest nearly or wholly regaining 618 PLEURISY: PARACENTESIS OF THE CHEST. its normal amplitude, the ribs and intercostal spaces sink down, and, as the integument is not displaced, the result is that the parallelism between the cutaneous wound and the pleural opening is destroyed. Of course it is not so completely destroyed as when my former little manoeuvre is adopted; but there is no necessity that it should be destroyed: and indeed, when the effusion is purulent, want of parallelism between the two openings is an evil. You understand, of course, that I am not now speaking of those cases in which it is necessary to leave a canula in the wound. Want of parallelism, which takes place spontaneously, would in such a case be a complication; and, besides, there can be very little use in endeavoring to prevent the entrance of air during the operation, when it will generally enter of neces- sity by the canula at a later stage. I at present only refer to cases of acute purulent effusion treated by simple puncture. In such cases, I say that a too absolute want of parallelism might lead to troublesome consequences. Generally after seyen, eight, ten, or fifteen days, a new purulent secretion has taken place, and then the pus discharges by the wound, which opens spontaneously, as you saw occur in a female patient who occupied bed 25 of St. Bernard's Ward. If, then, the opening in the pleura does not in any way correspond with that in the skin, the pus will burrow sinuously under the integuments, causing separation of tissues and fistulm difficult of cure. Let us now revert to the operation itself. The trocar has penetrated the pleural cavity-a fact ascertained by feeling that its point can be moved about freely in a hollow space: the stylet is withdrawn, care being taken to open out the membrane, temporarily folded round the handle of the instru- ment, which has to serve as a valve: the membrane must be unfolded in such a manner as to secure the valvular action which it is meant to perform. On the withdrawal of the stylet, the fluid at first flows slowly, then in a continuous jet, and at last in jerking gushes : I shall afterwards explain to you the cause of these differences in the modes of flowing. During expira- tion, the membrane is raised up by the outflowing matter; and during in- spiration, it rests in exact apposition bn the grooved expansion of the canula. When the flow stops, when the wished-for quantity of fluid has been ob- tained, the instrument is withdrawn by a quick movement: the little drops of serosity and of blood are wiped from the small wound, and the Maltese cross of court plaster, or of diachylon plaster, is applied to it, when thus freed from moisture. You will no doubt, gentlemen, meet with an occurrence which has two or three times happened to me, and which you have witnessed in our wards. On withdrawing the stylet, or on your attempting to do so, not a drop of fluid passes through the canula, or if there be any flow, it is very small. This is an accident for which you ought to be prepared ; for you can under- stand that its occurrence will occasion you disappointment and annoyance. You have in a positive manner convinced yourself that there is effusion into the pleura: mensuration and percussion of the chest have demonstrated to you that the quantity of effusion is great: you have announced to the rela- tions that you are about to draw off three litres of water from the chest: you introduce the trocar, and not a drop comes! How is this to be ex- plained ? Suppose a physician performed paracentesis for the first time. His diag- nosis is precise: he lias accurately ascertained the position of the thoracic viscera : he has felt and heard the pulsations of the apex of the heart: he has marked the limits of the space occupied by that organ ; and still, he cannot divest himself of a certain amount of misgiving. Even when the effusion is on the right side, when the heart is consequently remote from the point where the puncture has to be made, he hesitates: though he would pleurisy: paracentesis of the chest. 619 operate boldly if he had to perform abdominal paracentesis-a more dan- gerous operation than thoracic paracentesis-he stays his hand; and here is what may be the result of this hesitation. The costal pleura is sometimes lined by layers of false membrane, which may perhaps be a centimetre in thickness. During the first eight, ten or fifteen days of the pleurisy, this pseudo-membranous layer does not adhere firmly to the costal pleura, and offers such an amount of resistance that there is difficulty in tearing it. In timidly puncturing the chest, in place of piercing right through this layer, the trocar raises it up in such a manner as to form an accidental cavity between the false membrane and the walls of the chest. If, with a view to ascertain the cause of the obstacle to the flow of the liquid, a probe is introduced through the canula, a resisting body is felt, which follows the movements of inspiration and expiration : under these circumstances, the operator cannot get rid of the idea that he has come upon the lung, and though convinced of the accuracy of his diag- nosis, the frightened physician dare not continue the operation. It is necessary in such cases, to endeavor to tear the false membrane, by using the perforator of the trocar, introduced through the canula, and pushed in more deeply, or by using a probe or a crochet needle; the latter being an excellent instrument for the purpose. Should these attempts prove unavailing, it will be necessary to make a new puncture in one of the inter- costal spaces above that in which the first was made. Specially bear in mind, that if it be necessary to proceed gently in the first stage of the introduction of the trocar, that is to say, whilst the muscles are being perforated, you must proceed quickly in the second stage, that is to say, after you have perforated them. By holding your instrument, so as to leave free about three centimetres, you have nothing to fear, for your own finger will prevent you going farther than you wish. By employing a quick manoeuvre, the false membrane cannot fly before your trocar, and you will be certain to penetrate the pleural cavity. There are other cases in which paracentesis has been performed accord- ing to rule, cases in which you have unquestionably penetrated into the pleural cavity, but in which the effusion only flows drop by drop: you have then to do with a circumscribed, which you must not confound with an encysted, pleurisy. The serous exudation is imprisoned within fibrinous partitions: these encysted pleurisies communicate with one another, or at least the fluid passes from one into another, but it passes slowly, drop by drop. In these cases, you must endeavor to destroy, to tear, the fibrinous walls, employing the canula, a probe, or a crochet needle; and when you have done so, the flow becomes a little more free. I ought to add, gentle- men, that cases of this description are not common. Here, however, is a case, which you will often meet with. The canula is in the midst of the effusion ; but nevertheless, there is no flow. That depends upon the manner in which the patient breathes. Whether it be from a certain nervous feeling, pr from a habit which he has acquired, he breathes only with the lung of the healthy side; on the other hand, the lung of the affected side, completely squeezed up against the vertebral column, contains no air, so that there is no pressure exerted from above downwards on the fluid to promote its flow. The flow does not begin till the patient is told to take deep inspirations; or better still, to strain as if at stool. The effusion then gushes through the canula, and after a certain time dribbles out, the gush being resumed only when respiratory or straining efforts are made. The glottis being closed, the air, which cannot escape by the superior opening of the windpipe, continues to distend the lung; 620 pleurisy: paracentesis of the chest. the capacity of the pleural cavity being at the same time diminished by the contraction of the expiratory muscles and of the diaphragm, the effused fluid, solicited from all parts to effect its exit by the opening made into the chest, escapes in jets, the spurts corresponding with the respiratory move- ments and the expiratory efforts. The exertion of coughing produces similar results. Though at first it is necessary to ask the patient to cough, that is soon not required. The per- son who only coughed when ordered to do so, at last has frequent and in- voluntary coughing fits, because the lung, which has not breathed for a long time, experiences, when the air enters and opens up the air-vesicles, a sort of irritation, a sort of excitement, from coming in contact with its natural stimulus, to which it had become unaccustomed. This involuntary cough may become very violent, very frequent, and very painful, and may resist all treatment. Dr. D., whose case I related to you, complained of experiencing such severe pains when the air entered the chest as made him afraid to breathe; his respiration was short, jerking, and sobbing; and an hour and a quarter elapsed before it calmed down. This fatiguing cough sometimes did not come on till very late in the day. The pains which accompanied it seemed to me to depend on the tearing of the false membranes, by which the lung was adherent to the vertebral column. Besides being useful by promoting the issue of the fluid, the exertion of coughing, the fits of cough, are beneficial by preventing syncope, when the occurrence of this complication has to be dreaded. By chasing and driving the blood to the brain, these efforts produce a kind of cerebral plethora, which is antagonistic to the occurrence of syncope. Towards the completion of the operation, the fluid which flows from the canula generally presents changes of color. The serous effusion has then a red tinge from its admixture with blood, and very frequently the fluid is almost pure blood. This occurred in the young lad whose case Dr. Moynier published in the Bulletin General de Therapeutique. I saw the same in a little girl, in whose case I was consulted by Dr. Dumont- pallier. The patient to whom I refer was a girl eight years old, who neither com- plained of shortness of breath nor embarrassment of breathing, although for some time she bad difficulty in running or going up a stair, and was tired by the least exercise. She said that she had no pain anywhere. Nevertheless she grew so thin, and her appetite became so flagging, that the mistress of the boarding-school where she was placed gave notice of her being an invalid to her parents, by whom she was taken home. At that time the patient had very evident dyspnoea, yet she made no complaint regarding it. Inspiration was short and frequent: the pulse was small, wiry, and very quick. There was a small dry cough. On examin- ing the chest, one was struck with the deformity of the thorax. On the left side, the lower ribs were prominent in front, and described a convex line more elevated than that formed by the corresponding ribs on the right side. The intercostal spaces were obviously flattened, an appearance which was rendered more evident by the emaciation of the child. Costal respira- tion seemed to be performed only on the right side. The antero-posterior diameter of the chest was greater on the left than on the right side. The apex of the heart did not beat under the left mamma, but beneath the sternum. When the hand was placed on the trunk, the child at the same time being made to speak, no thoracic vibrations were felt. There was absolute dulness on percussion from above downwards, in front, behind, pleurisy: paracentesis of the chest. 621 and laterally, ascending as high as the subclavicular and infraspinous re- gions, and unaccompanied in front by any skodaic resonance. On auscul- tation, it was found that the respiratory murmur was entirely absent from tlje whole of that side of the chest; but above, along the vertebral column, in a space consequently corresponding to the bifurcation of the bronchi, a blowing sound and vocal resonance were heard. On the left side there was exaggerated resonance on percussion, with respiration puerile and sup- plementary, without rales or other abnormal sounds. There was evidently extensive pleuritic effusion on the left side. Dr. Dumontpallier, thinking that paracentesis was indicated, asked me to see the case in consultation with him. There was no room for hesita- tion : I forthwith performed the operation. It occasioned little pain. The fluid evacuated was a perfectly limpid serosity, which at first was of a green- yellow, and towards the end of the flow of a red color. There were some sanguinolent striae which fell to the bottom of the vessel, and afterwards there came several spoonfuls of a serosity resembling pure vermilion blood. I withdrew the canula, and closed the wound by applying a piece of diachylon plaster. The quantity of fluid evacuated weighed 670 grammes. The phenomena which followed the operation presented nothing worthy of special mention. A perceptible change very quickly took place in the condition of the child. Ten days after the tapping, she was sent to the country, and after a month's residence there, she had regained her good health. All that remained of her malady was flattening of the chest on the affected side, and this was showing a visible tendency to diminish. The cause of the flow of blood may be lesion of the small vessels which enter into the structure of false membranes which are becoming organized. The false membranes are torn by coughing, and by the expansion of the lung; and to their laceration so caused, we must attribute, not only the slight hemorrhage now under consideration, but also, as I have already remarked, the pains (sometimes pretty acute) of which patients complain -pains also, in part, the consequence of irritation of the bronchial tubes from the contact of air by which they have been long untraversed. The flow of blood may also be explained by supposing that, at the time when the lung opens out, the pleura, intimately united to the false membranes, is separated at some points from the lung or from the ribs, in, such a vio- lent way as to tear some of its vessels. The fluid evacuated from the pleural cavity, on cooling in the vessels in which it has been collected, forms into a jelly. In the more active pleu- risies, it is very limpid, and presents a greenish-yellow color: and in such cases, it is not unusual to find it some hours after cooling with a rosy tint due to the globules of blood which it contains, and presenting an appear- ance which may be most appropriately compared to slightly tinted white gooseberry jelly. During the operation, and as soon as a certain quantity of fluid has been evacuated, a change takes place in the plessimetric and stethoscopic phe- nomena. There is a return, from above downwards, of the resonance on percussion ; and, at the same time, on applying the ear to the chest, the sound of vesicular expansion is heard, first at the summit of the lung before and behind, and then progressively throughout the whole extent of the diseased side. This pulmonary expansion is accompanied by mucous and subcrepitant rales, produced by the passage of the air into the vesicles, which contain mucus secreted by the surface of the bronchial tubes, and also by the unfolding of these vesicles. This unfolding sometimes gives rise to true crackling. There has been discussion as to whether it is advantageous to evacuate 622 PLEURISY: PARACENTESIS OF THE CHEST. at once the fluid effused into the pleural cavity. I do not understand why any inconvenience should result from doing so; and, for my own part, have never seen the slightest danger from the proceeding. The only undesirable occurrences which I have observed have been the pains and the hemor- rhages of which I have spoken-accidents of no special seriousness. I believe, indeed, that there is a great advantage in emptying the chest as completely as possible, as this is the best means of putting the lung into favorable conditions for expanding freely, and consequently of expediting the cure. You perceive, gentlemen, that the shorter the period during which the fluid remains in the pleural cavity, and the more complete is its removal, the greater will be the power of expansion, because the lung is entirely obedient to the pressure 'exerted upon it by the air, which entering by the trachea, fills the bronchi and their ramifications, even to the vesicles. Besides, when we possess a means of cure so prompt, and so free from dan- ger, why should we wait ? I am well aware that the physicians who, con- trary to my view, think that a part only of the fluid ought to be evacuated, base their opinion on the belief that in paracentesis of the chest, as in paracentesis of the abdomen, either a too rapid or too abundant subtrac- tion of the fluid may induce syncope. This remark leads me to speak of the objections which have been urged against paracentesis of the chest. It has been said that as syncope may supervene during or after the opera- tion, it is an accident against which precautions ought to be taken. With- out entering into a theoretical discussion on the point, I shall answer the objection by a statement of facts. Since I first performed, and have seen performed, paracentesis of the chest in cases of pleurisy, I have neither heard quoted, nor have I read, the history of any case in which this com- plication is mentioned. I admit that I once saw syncope supervene; but the occurrence took place under very peculiar circumstances, and not im- mediately after the operation. The case is so interesting, that I shall give you a full account of it. During the autumn of 1848, I was called in by Dr. Bonnassies to M. L., living at Paris, 19 Quai Bourbon, in the Isle St. Denis. M. L. had been gouty from his youth. So strongly marked in him was the gouty dia- thesis, that in addition to the chalky tophus which deformed all the joints, tophaceous concretions existed in the thickness of the skin of the hands and feet, to such a degree that the skin of these parts had the appearance of the internal surface of an aorta studded with ossific points. Two months pre- viously M. L. had been attacked by pleurisy on the left side. The affected side was entirely filled with effusion, the heart and diaphragm being pushed out of place. For several nights, he had had suffocative paroxysms, lead- ing to the dread of imminent death. As these attacks of dyspnoea super- vened on the slightest movement, it was necessary for the patient to take very careful precautions when he made water or went to stool. Paracentesis was decided on, and was performed. The operation pre- sented this special feature, that at each cough the lung struck against the canula. I evacuated 2200 grammes of a purely limpid lemon-colored se- rosity. The lung unfolded; and immediately after the operation, there was heard, in the whole of the left side, the respiratory murmur, mingled with some mucous and subcrepitant rales. I ought, however, to state that the opening out of the lung was exceedingly painful: the pain continued till the following morning. M. L. declared that he was familiar with that sensation : that it differed in no respect from that which he experienced when the gout invaded the thoracic walls. There was high fever; but there pleurisy: paracentesis of the chest. 623 was no return of the effusion, and the rales were coarser. There was no symptom which foreboded a fatal termination. M. L. was a man of very violent temper. Notwithstanding my formal orders to the contrary, he left his bed to go to stool. He got up, took some steps, then sat down on the convenience, and after some minutes spent in un- availing efforts he returned to bed. Again he tried, but fruitlessly. He felt great oppression of the breathing. But he declared that he should make one more attempt. Neither the advice nor the entreaties of his family availed to induce him to desist. He resolutely got out of bed, sat on the night-stool, where for some time he made new and unavailing efforts ; he then regained the side of his bed; and when attempting to step in, he expired. When we consider this case in an impartial manner, we cannot impute death to the paracentesis; indeed, we may say that the fatal issue would have occurred sooner, if, before the operation, the patient had been placed in the same physical and moral conditions. Syncope, then, is a very rare accident as a consequence of paracentesis of the chest, judging by the published accounts of cases in which this opera- tion has been performed, and by the numerous cases which I have seen. No doubt it may occur, but when it does occur, is it to be attributed to the paracentesis? Ought it not rather to be attributed to the circumstances, to the organic conditions, which necessitated surgical interference, and which are not always immediately altered by the removal of the fluid from the chest? To avoid the risk of this complication, which may prove fatal, the pa- tients ought to be recommended to give both body and mind the greatest possible amount of repose after the operation. The same advice, however, is necessary when there exists a large amount of effusion, particularly if it has displaced the heart and large vessels. When I communicated the case I have now laid before you to my col- leagues of the Medical Society of the Hospitals, one of them asked whether the sudden death might not be attributed to rupture of the pulmonary vesi- cles, and the introduction of air into the veins. To that question, I would reply that this alleged rupture was either very late in occurring, inasmuch as death did not take place till the day after the operation ; or, that if the rupture happened at the time when the fluid was evacuated, it is impossi- ble to understand how the entrance of air into the veins should have been so long delayed. It has been alleged that sanguineous expectoration sometimes follows the coughing fits with which patients are seized during the evacuation of the effusion. Cases of this description have been quoted; and they have been explained in the following manner. The rapid unfolding of the lung, by promoting a sudden afflux of blood from the pulmonary and bronchial vessels, leads to congestion of the lung, of such an active character as to rupture vessels and cause hemorrhage. I admit the possibility of such an occurrence, although I have never seen anything more than a frothy, somewhat rosy, expectoration ; but I cannot accord to the accident that importance which the opponents of the operation would seem to attach to it. I shall not stop longer at the other objection, viz., that in performing paracentesis there may be a risk of wounding the intercostal artery. By making, with the precautions which I have indicated, the puncture in an intercostal space, by, in the first instance, incising the skin so as to enable the pleural cavity to be penetrated without an effort-the manual operation becomes exceedingly simple, and much less liable to mishaps than bleeding from the arm, or opening an abscess-operations which we 624 PLEURISY: PARACENTESIS OF THE CHEST. nevertheless intrust to the most inexperienced. Who, I ask, has seen these lesions of the intercostal artery? Your teachers of surgery have informed you that in sword wounds this vessel is seldom injured. The anatomical disposition of the parts explains the rarity of the occurrence, for the inter- costal artery is placed in the groove of the bone, which circumstance, and the smallness of its calibre, protect it from being wounded. This, then, is an objection which spontaneously falls to the ground. This cannot be said of other objections of which I am now going to speak. Though they admit of being very easily refuted, they are of sufficient im- portance to require to be discussed. I begin with the statement to the effect, that the operation has been useless, when tapping has been performed for effusion in acute pleurisy, and the effu- sion has been reproduced by the continuance of the pleurisy renewing the pleuritic secretion. The possibility of. the reproduction of the fluid cannot be denied. Two things have to be considered in pleurisy with effusion. Pleurisy, properly so called, inflammation of the pleura, lasting for eight, ten, or fifteen days; and the effusion, which is at first under the influence of the inflammation, remains for a longer or shorter period after the inflammation is at an end, just as a collection of pus in the cellular tissue remains after the inflamma- tory condition which gave rise to it has passed away. The collection of pus, or the serous effusion, are effects, the results of a pathological action which constitutes phlegmon or inflammation ; but they must not be con- founded with it. I take for granted, that at the time when the excessive quantity of the effusion necessitated the operation, the pleurisy still continued. To give precision to the question, let me put a case with figures: I assume that the pleurisy has gone on for twelve days, and that its natural course will be to continue for three days longer: in such a case, we may possibly see the resulting effusion increased or reproduced during that period ; but let us inquire what are the consequences of the surgical interference judged so opportune. Suppose, for example, that there were three litres of effusion, and that by the tapping I evacuated two and a half. Suppose, that after the opera- tion, one litre was secreted, the remaining effusion would only be a litre and a half, only the half of what it was originally, a quantity which might continue to exist without causing the risks incident to an excessive amount of effusion-taking no account of the fact, that we should have had not three but four litres of fluid in the pleural cavity. In place of allowing the state of the patient to become worse, we have granted time to the inflam- mation to terminate without inducing accidents ; and also by withdrawing a portion of the fluid, we have made the absorption of the remainder a more easy process. Moreover, gentlemen-to continue the comparison which I have just instituted between pleuritic effusions and purulent collections-pus, when shut up in its circumscribed locality, becomes a source of inflammatory action, and is then a foreign body seeking to be eliminated from the living parts : fluid effused into the pleural cavity may likewise excite inflamma- tion. To put an end to the inflammation occasioned by the presence of pus, the best thing which can be done is to open the abscess, and the quickest method of terminating an inflammation excited by pleural effusion is at once to relieve the pleura from the presence of the cause of the inflamma- tion. To accomplish this object, paracentesis is unqestionably the most expeditious and certain measure which can be adopted. I have no objection to admit that effusion may be reproduced to such an PLEURISY: PARACENTESIS OF THE CHEST. 625 extent as to necessitate a repetition of the tapping. But what objection can there be to the repetition of an operation which is so absolutely devoid of danger? It has been said that upon this principle, the patient, soon exhausted by sucqessive tappings, must inevitably sink into marasmus. This inevitability is, in my opinion, anything but demonstrated. We very seldom require to repeat the operation several times in the same individual, when the affection is simple acute hydrothorax. Reproduction, when it does take place, is never to the extent of the original effusion; and gener- ally, the fluid is absorbed. Generally, a single tapping suffices, and it is an exception to the rule to require to perform the operation twice in the same case. I admit, however, that the effusion may be reproduced to such an extent as to necessitate several repetitions of the paracentesis. Why should we pursue a different plan in pleuritic effusions from that which we adopt in ascitic effusions ? Has the quantity of fluid which we withdraw from the pleural cavity, relatively small as compared to that which we are constantly in the habit of withdrawing unhesitatingly from the peritoneum, the special power of debilitating the patients and plunging them in maras- mus? No one will venture to say so. The theoretical objections to para- centesis are completely refuted by the imposing mass of clinical facts which demonstrate, to all true practitioners, the chimerical character of the oppo- sition which some adduce to the operation I defend. Some physicians have maintained that the duration of pleurisy is pro- longed in place of being curtailed by paracentesis, the traumatic condition consecutive to tapping being, according to them, a new cause of inflammation of the pleura. It is easy to refute this objection, not only by appealing to clinical facts, but likewise by referring to what has been observed in experi- ments made on animals, and to the recorded cases of wounds of the chest in the human subject. When the chest of an animal is punctured by a pointed instrument, whatever number of punctures may be made, we find, on killing and exam- ining the animal, nothing more than a little effused blood in the neighbor- hood of the wounds, and traces of slight inflammation, extending sometimes around the wound to the distance of half a centimetre. You are aware of the small amount of seriousness which attaches to wounds of the chest made by puncturing or cutting instruments; and that whatever they may some- times possess that is formidable depends on the complications which ac- company them. If pleurisy has been mentioned as one of these complica- tions, care has been taken to add that it remains local and benignant, so long as there is neither effusion of blood nor entrance of air into the chest; and so long as no foreign body, such as a fragment of the sternum, or of a rib, fall into the pleural cavity-in which case a suppurative pleurisy supervenes. Leaving these special complications out of account, wounds of the chest, even those inflicted by very large instruments, are free from danger; but still more exempt from risk must be the little wound of the trocar, made with all the precautions necessary to prevent the entrance of air into the pleural cavity. Interrogate the patients who have been the subjects of paracentesis, and they will all tell you that they experience no pain in the situation in which the instrument penetrated the chest. If the effusion in- crease consecutive to the operation, this increase results from the pleurisy which existed prior to the operation not having been extinguished; and there is no ground for concluding that there is an exacerbation of the in- flammation, as the quantity of fluid left in the pleural cavity, in place of being augmented, usually decreases. In early times, when the operation was somewhat of a novelty, it was vol. I.-40 626 pleurisy: paracentesis of the chest. excusable for Stokes and Watson to entertain the fear that paracentesis of the chest might convert a serous into a purulent effusion, but now that ex- perience has superabundantly demonstrated that the fear was groundless, to bring forward an argument of this description against the operation is either an indication of bad faith or of unpardonable ignorance. In this matter, gentlemen, I appeal to such of you as regularly follow the practice of my clinical wards. The most serious accident, and indeed the only one to be feared in para- centesis of the chest, is the persistent entrance of air into the pleural cavity, inasmuch as it may cause suppurative inflammation; but this danger has ceased to be a serious objection to the operation, because-thanks to the improvements in the method of performing it-thanks to the valve added to the canula-the entrance of air into the pleural cavity is no longer a possibility. To complete my remarks upon the subject of paracentesis, I have a word to add on the consecutive treatment, which is just the treatment of ordinary pleurisy. To expedite the resolution of the effusion, to facilitate the absorp- tion of the remains of the fluid not evacuated by the canula, I prescribe digitalis to be taken internally: I generally order an infusion of 50 centi- grammes [nearly 8 grains] of the leaves in a litre [rather more than a quart] of water. I likewise order the affected side to be painted with tincture of iodine, the resolutive influence of which I consider as at least as powerful as that of blisters. Hitherto, gentlemen, I have spoken to you only of paracentesis in cases of serous effusion. In purulent effusion, the operation must be performed in a different manner. Although, from the symptoms which I have indicated, you may infer the existence of a purulent pleurisy, you can only in particular cases attain sufficient certainty on this point, to dispense with the precautions which ought to be taken when the effusion is serous. You begin, therefore, by puncturing the chest with the trocar: you withdraw the canula, and per- form the dressing as in a case of simple hydrothorax. It may happen sometimes, though seldom, that there is no new effusion; or, the effusion may recur and be evacuated by the bronchial tubes, -which is a still more unusual occurrence, and one which, relatively, is very favorable. Almost in every case, however, the purulent fluid reaccumulates, and the original wound made by the trocar, opening spontaneously, gives issue to the pus. A fistula is afterwards established, which will not close till the cure is com- plete, or till the pus finds an exit by the bronchial tubes, as I have just stated may occur. If, through some unusual circumstance, the pus flows only in small quantities, the chest may become flattened, at the same time that the lung resumes its place, and then the cure is accomplished without the occurrence of pneumothorax. Generally, I might say, in nearly all cases, a very large quantity of pus is discharged, and is replaced by air entering the chest: the result is hydropneumothorax, for which surgical interference will afterwards be required. In such cases, you enlarge the wound with the bistoury, so as to allow a larger canula to be introduced, which has to be left in the wound. The canula ought to be of metal, and bent in such a manner as not to injure the lung as it expands. The rim of the canula is furnished with a caoutchouc ring, which, by coming between the instrument and the skin, prevents excoriation. In cases of this description, so far from regetting a want of parallelism between the external and internal openings, as in cases of serous effusion, it is essential that the parallelism be as complete as possible. The introduc- tion of air into the pleural cavity ceases to be a cause of dread, as you are pleurisy: paracentesis oe the chest. 627 going to endeavor to modify the condition of the diseased serous membrane by applying to it the tincture of iodine, or some other irritant fluid. The absence of parallelism between the openings would make it more difficult to retain the canula in its place, and would also lead to the formation of abscesses and subcutaneous fistula;. Nevertheless, it is necessary to prevent air from entering in great quantity, because its presence in the chest would impede the action of the lung, and produce irritation of the pleura of an injurious character. Hence, the incision made with the bistoury ought not to be more than just sufficient to permit the passage of the canula. When you have made the incision, you allow a large portion of the effused pus to flow, without, however, completely emptying the pleural cavity, though this I consider useful in cases of serous effusion. You then inject a solution of iodine. The following is the formula for preparing the injection which I employ: Tincture (French) of Iodine, . . 50 grammes. Iodide of Potassium, .... 2 " Distilled Water, 100 " The injection consists of the above solution, with the addition of an equal quantity of tepid water. You tell the patient to move about in such a way as to cause the injec- tion to come in contact as much as possible with the surface of the pleura. You then allow a part of the fluid to escape, so as to prevent the iodine from producing toxic effects, which, though they might probably not be serious, ought not the less to be guarded against. You close the canula, and you put large bands of adhesive plaster round the chest. You open the canula daily to allow a certain quantity of fluid to escape; and you repeat the injection, increasing or diminishing the quantity injected, and the proportions of the tincture employed, according to the degree in which the pleural cavity tends to contract, according also to the greater or less fetor of the fluid which it contains, and its greater or less approxima- tion to the character of laudable pus. The injection is then repeated only once in two, three, or four days; taking care, however, to empty the chest at least once in the twenty-four hours. It may be necessary to continue this treatment for a long time: in chil- dren, I have continued it for four, five, and even six months. These are the cases, gentlemen, in which we see very considerable defor- mities of the chest. The chest becomes flattened; and the individual is forcibly bent to the affected side, his shoulder approximating to the base of the thorax, which presents a notable contraction, varying from two to seven centimetres. In front, there is very great flattening, and the clavicle projects: there is also flattening behind. You understand the mechanism by which this deformity is produced. The lung, by means of false membranes, is squeezed back, and kept in con- tact with the vertebral column, near the root of the bronchi: when the effused fluid has been almost completely evacuated, a vacuum is produced in the chest at the moment the ribs ascend, particularly at the time the diaphragm descends: the pressure of the atmosphere then compresses the thoracic walls, whereas in the normal state, the equilibrium is maintained by the vacuum which has a tendency to be produced during inspiration being filled up by air rushing into the bronchial tubes. This deformity, which increases, and sometimes assumes formidable pro- portions in young subjects, produces alarm in families. Dispel their fears: when once the effusion has been cured, the deformity will disappear. In children, although the thoracic deformity assumes, as I have said, a formida- 628 PLEURISY: PARACENTESIS OF THE CHEST. ble appearance, it is seldom painful; but in adults, whose bones are less easily bent, the pains are sometimes intolerable, a fact which you ought to bear in mind, so that you may not impute the sufferings of the patient to some serious lesion. As the quantity of fluid in the pleural cavity diminishes, the lung will respond to the pressure of the atmospheric air. which will at each in- spiration-that is, from twenty to twenty-five times a minute-enter the bronchial tubes. You can understand how great must be the effect of this pressure repeated an immense number of times in the twenty-four hours: you can understand how the lung, under the influence of this pressure, dis- engages itself from the adhesions by which it is confined, and expands suffi- ciently to resume, to a certain extent, its place in the thoracic cavity. The flattened ribs are approximated to the lung, having gone half way to meet it, if I may so express myself. The thoracic deformity, then, is a condition favorable to the cure of effu- sion, inasmuch as it diminishes the containing cavity, while by the lung progressively expanding, the capacity of the cavity is likewise lessened, till at last, there only remains a sort of small pouch, which closes spon- taneously. In adults, and still more in old people, in whom the thoracic walls, being more rigid than in children, yield less easily to the pressure of the atmos- phere, the deformity is much less observed. This, probably, is one of the reasons why chronic purulent pleurisies, from which in childhood recovery generally takes place, are almost always fatal in old age. Gentlemen, before concluding these lectures on paracentesis of the chest, let me mention an additional case, interesting in more than one aspect, and which is peculiarly fitted to demonstrate the advantages-to me incontest- able-of this operation, as well as its harmlessness in the very cases in which it seems to be most contraindicated on account of the complications which accompany hydrothorax. You have all seen the subject of the case to which I refer: he was a man who lay in bed 25 of St. Agnes's Ward, to which he was admitted as a patient on the 11th April, 1863. I cannot do better than read the history as written out in detail by Dr. Michel Peter, my chef de clinique.* "A man, aged 36, was admitted to Dr. Trousseau's clinical wards on the 11th April, 1863, and placed in bed 25 of St. Agnes's Ward. " He stated that his illness had commenced three months previously, and that up to that date, he had had neither cough nor oppression of breathing. Subsequently, he had both, as well as spitting of blood from time to time. " On admission, he was diagnosed to be suffering from a serious lesion of the left side of the heart; viz., insufficiency of the aortic valve, probably combined with contraction of the orifice. The heart was greatly hyper- trophied : and over the precordial region, the chest was arched. At the base, accompanying the second sound, there was loud though soft blowing; and with the first sound, there was blowing of a much less decided charac- ter. In other words, the signs of insufficiency of the aortic valve were much more marked than the signs of contraction. The pulse was bound- ing, as in cases of insufficiency. There was oedema of the inferior extremi- ties, which had existed for three weeks. " On the 14th May, after great oppression of breathing, the patient spat blood in large quantity. The blood was not red-not vermilion and frothy-as in tubercular haemoptysis: it was blackish, or mixed with bron- * Peter (Michel): Gazette des Hopitaux, 13th June, 1863. PLEURISY: PARACENTESIS OF THE CHEST. 629 chial mucus, as in pulmonary apoplexy. In fact, an attack of pulmonary apoplexy had supervened. "Next day, 15th May, the patient complained of pain in the left side of the chest, of so violent a character as to cause him to utter piercing cries. On auscultation, however, nothing remarkable was heard. " On the following day, 16th May, slight crepitation was heard when the ear was applied over the axillary margin of the scapula. "On the 17th May, a superficial harsh, noisy sound had taken the place of the crepitation of the previous evening. There was marked dulness in the lower third of the chest. The pleuritic pain continued with diminished intensity. " On the 18th May, all the indubitable signs of effusion were present, There was dulness in the two lower thirds of the left side of the chest, in which situation the vesicular murmur could not be heard. Posteriorly, at the junction of the upper and middle third of the chest, there was typical blowing and segophony. The pain was still very acute. " On the 19th May, there was, posteriorly, dulness at the summit of the chest, and, anteriorly, skodaic resonance. The heart was inclined to the right of its natural place. The breathing was very much oppressed. Ex- treme anxiety existed, having as its causes, the cardiac disease, the turning of the heart on its own axis, profuse effusion, and continuance of the pain. " On the 20th May, numerous causes of impediment to the function of htematesis induced Professor Trousseau to have recourse to paracentesis; and the operation was on that day performed by M. Peter, his chef de clin- ique. From the puncture made in the sixth intercostal space and in the axillary line, there issued 2000 grammes [more than two quarts'] of serosity, which, though rich in fibrin, was unmingled with blood. The fact that hsematopneumothorax did not exist was established by there being no blood in the serosity evacuated ; and that the hydrothorax was not simple was shown by the secrosity being fibrous: in other words, there was a true pleurisy. " The evacuation of the serosity was followed by great relief. But three days later, there was a recurrence of the pulmonary apoplexy, which led to the return of the pains, and a reproduction of the effusion. " On the 25th May, the sixteenth day after the paracentesis, the effusion was as high up as the first rib. The apex of the heart was beating below the right nipple. As there was very great oedema of the lower extremities, friction with croton oil was ordered, with a view to bring about the dis- charge of the serosity with which the cellular tissue was infiltrated. " On the 29th May, thanks to the frictions with croton oil, the serosity flowed in very great profusion from the legs. The patient was altogether in a better state. "Although, however, the thoracic effusion was a little diminished, it was necessary to repeat the puncture of the chest on the 31st, when there was drawn off 1700 grammes of a serous fluid absolutely similar to that obtained by the first paracentesis. This second operation was followed by fits of coughing, during which the lung was heard to unfold and resume its place, whilst at the same time the heart was observed to return towards its normal position : its pulsations, however, were still a little nearer than natural to the median line. • " From the date of the second operation, respiration was audible through- out the whole of the left side of the chest, though the sound was obscured by false membranes which lined the pleura. There was no return of the effusion. " Ten days have now elapsed since the second operation was performed, 630 pleurisy: paracentesis of the chest. and since that time a state of agonizing suffering lias ceased, the long con- tinuance of which was incompatible with life, judging from the circumstance that the effusion had just been added to numerous other risks of death, sup- pressing, so to speak, one entire lung of a man in whom hsematosis was already interfered with by heart disease. " It will no doubt be observed that, without being dependent on the affec- tion of the heart in respect of the hydrothorax, the pleurisy was in this case indirectly connected with the cardiac disease. The pulmonary apoplexy was the link which united the disease of the heart with the pleural effusion; not that there had been rupture of the pulmonary pleura and sanguineous effusion into the cavity of the chest (for the absence of color showed that this had not occurred), but that some superficial clots had irritated the pleura, and had so determined serous exudation. " Ought we in this case to dispute the utility of paracentesis of the chest, because there was recurrence of effusion after the first tapping? Before doing so, it would be necessary to forget that the evacuation of the fluid, in all probability, prevented the patient from dying in a state of asphyxia, or from sudden syncope. The duration, moreover, of the pleurisy was very short, if we compare its duration with that which it was natural to expect from so profuse an effusion in a man doomed by the cardiac disease to serous infiltrations, and whose tissues were consequently in a condition ill suited to accomplish absorption. "Perhaps there may be a reproduction of the fluid ; but should the gen- eral state of the patient be ameliorated, a third tapping may prolong the life of the patient, who, had it not been for the relief afforded by paracen- tesis, could not have supported two extensive effusions, and still less have been able to support a third without sinking under its consequences." Gentlemen, I entirely agree with the judicious remarks of Dr. Peter ; and I do so with the more satisfaction that the patient, still in our wards on account of his cardiac affection, for which we can do nothing, is at present relieved from certain serious symptoms, for which we can do something. The effusion in his case would have proved mortal, for it was not dropsy of the pleura, the final phenomenon of cardiac cachexia, from which he suf- fered, but a pleurisy consequent upon pulmonary apoplexy. From a con- viction of the utility, or I should rather say of the necessity, of our having intervened surgically on behalf of this man, I earnestly call your attention to his case, which, in my opinion, teaches more than one useful lesson. In connection with this case, the editor of the Gazette des Hopitaux men- tions that one of my pupils, Dr. A. Masson (of Yvetot), has published a memoir containing twelve cases in which he performed paracentesis of the chest. The note of the editor of the Gazette des Hopitaux is to the follow- ing effect: " In ten out of twelve cases, the operation was completely success- ful ; and the author being favorably situated for keeping his eye on the patients, was able to assure himself that the cure, almost always rapidly obtained, was final. Never was the cure impeded by the slightest compli- cation attributable to the paracentesis. In two cases only, the operation failed to effect a cure: or rather, in two cases, death occurred, notwithstand- ing the tapping. A woman tapped for tubercular pleurisy died of phthisis six months after the operation ; and a man suffering from hydropneumo- thorax, with abscess of the lung, died after having several times vomited enormous quantities of pus. "For most of the cases in which Dr. Masson operated, the heart was displaced by the effusion. His knowledge of the possibility of sudden death occurring simply in consequence of the greatness of the quantity of the effusion contributed not a little to divest his mind of all hesitation as to TRAUMATIC EFFUSION OF BLOOD INTO CHEST, ETC. 631 the propriety of operating. The case detailed in Dr. Masson's memoir strikingly illustrates this terrible termination of some pleurisies. " Dr. Masson also operated upon two patients in whom there was not much effusion ; but who nevertheless wasted away rapidly, leading to the fear that a sudden outburst of tubercular disease was impending. " Gentlemen, I have thought it right to lay before you these cases derived from the practice of one of our honorable colleagues. Taken along with others which you will find recorded in medical works, they corroborate all that I have said to you of paracentesis of the chest. I shall have a feel- ing of great satisfaction, if I have convinced you of the vast services which this operation can render, and if I can diminish the fears which it stil# inspires in the breasts of some physicians. [During the summer and autumn of this year [1869], I have had opportunities of seeing Professor Michel Peter perform paracentesis of the chest: and have also, both in conversations and in his clinical lectures at La Pitie, heard him give very able expositions of the subject. His practice strongly corroborates the teaching of Dr. Trousseau. Professor Peter, in his clinical lectures at La Piti£, laid great stress upon the fact, that a continuance of the febrile state was ordinarily opposed to the absolute and im- mediate success of the operation In such cases, from the inflammation not being extinct, reproduction of the effusion almost invariably takes place} and it may be necessary, according to the quantity of the effused fluid, to tap again or apply blisters. It sometimes happens that the new effusion becomes purulent; and that the original puncture in the thoracic walls becomes a fistulous opening. The patient may live, retaining this fistula for an indefinite period ; or he may be speedily carried off by hectic fever This latter termination, Dr. Peter has only seen three times in the very large number of cases in which he has performed thoracic paracentesis. In two of the three cases, the patients were highly lymphatic, though not tuberculous subjects : in the other case, the patient was rheumatic. These are facts which ought to be known. Besides the flow of bloody serosity of which Dr. Trousseau speaks, and which is characteristic of cancerous pleurisies, Dr Peter, in his clinical lectures, remarked, that the tapping itself might occasion the issue of bloody or sanguinolent serosity. Dr. Peter has twice met with this form of hemorrhage: both patients made com- plete recoveries. He attributes the bleeding in these cases to the trocar having torn some vessels belonging to very vascular false membranes. Blood is consequently, discharged into the pleura, which renders bloody the fluid issuing from the canula. It is obvious, therefore, that there is no great cause for alarm when the fluid drawn off is bloody, provided the patient is otherwise in a good state.-Translator.] LECTURE XXXIII. TRAUMATIC EFFUSION OF BLOOD INTO THE PLEURA- PARACENTESIS OF THE CHEST. Effusion of Blood into the Cavity of the Pleura mechanically arrests Traumatic Hemorrhage.-In such cases Paracentesis is not only useless, but may even prove injurious.-The Blood coagulates immediately.-It scarcely irritates the Pleura.-Reabsorption takes place very rapidly. Gentlemen : In one of my previous lectures I spoke to you of serosan- guineous effusion into the pleura, recurring sometimes in an acute manner, particularly during eruptive fevers, and in a chronic form, when there is cancerous disease of the pleura. I now propose to speak to you of san- 632 TRAUMATIC EFFUSION OF BLOOD INTO CHEST: guineous collections formed in the pleura consequent upon wounds of the chest. Although effusion of blood into the pleural cavity is a subject which be- longs more particularly to Surgery, and may seem to be somewhat foreign to a chair of Clinical Medicine, I think it right to go into the subject, rather than leave you in ignorance of what I know about it. I think so, because it is a pathological question in relation to which I have made many experi- ments, the results of which have not received adequate publicity*-and, also, because sanguineous effusions into the pleura very frequently occasion attacks of pleurisy and empyema, thus bringing them, to a certain extent, within the domain of medicine. What ought the physician to do when a wound of the chest is followed by an effusion of blood into the pleura? Many surgeons inculcate the withdrawal of the blood by suction of the wound: some have recommended tapping, and others have counselled the removal of the effused blood through an incision in an intercostal space. Allow me, gentlemen, to discuss these different proceedings; but, in the first instance, let us endeavor to understand the indications which present themselves. Let us suppose that there is a great sanguineous effusion ; for as yet no one has recommended active interference in cases of very limited hemorrhage. There are two sources whence extensive hemorrhage may arise: from an artery of the thoracic walls, or from one of the vessels of the lung. If the hemorrhage come from one of the vessels of the walls of the chest, I cannot conceive the least benefit to result from any of the dif- ferent proceedings of which I have just been speaking: I could better under- stand how pressure exerted on the opening by the accumulated blood might assist in the formation of a clot, and so plug the vessel. But if the hemor- rhage come from the lung, it is easy to see that the effusion itself will be one of the most important curative agencies. In proportion to the degree in which the blood is effused into the pleura, the lung is flattened and squeezed up; and at last the cut vessels cease to bleed, because they are strongly compressed. In this way the effusion materially assists in accom- plishing the cure. When a horse is wounded in the lung a curious occurrence takes place. If a vessel of large calibre is cut, profuse hemorrhage takes place into the pleura, while, simultaneously, the blood flows into the bronchial tubes, and in a short time the animal dies. But if only some of the vessels of secon- dary size have been wounded, a rather profuse hemorrhage takes place into the pleura, and on the bronchial surface: soon, however, from the accumu- lation of effused blood compressing the lung, the hemorrhage ceases. If the animal be killed soon afterwards, there is found in the lung itself, besides the effusion of which I have just been speaking, an exceedingly curious lesion, which as yet has been very ill described. In the whole course of the penetrating wound, the pulmonary cells are infiltrated with blood, and this infiltration extends from one to several centimetres. The blood effused into the cells is much blacker, and much more minutely infiltrated in the immediate vicinity of the passage made by the instrument inflicting the wound; and in that situation there are structural changes identical with those which characterize recent nuclei of pulmonary apoplexy. The passage made by the instrument is itself closed by fibrin, a true coagulum occupying the course of the wound, just as a blade fits into its sheath. This protective clot is sometimes found half an hour after the wound * The results of the experiments made in 1829 by M. Leblanc and me were pub- lished in 1834, in the "Journal de Medecine PARACENTESIS. 633 has been made. It is imbedded in the interlobular cellular tissue, or in the cells, by innumerable fibrinous roots, which break when an attempt is made to tear it out. If the autopsy of the animal be not made for forty-eight, or seventy-two hours after the infliction of the wound, the wound is found to be closed by a most remarkable process. The lips of the wound of the lung are in- flamed, and the pleura surrounding it, to the extent of several centimetres, participates in the inflammation ; a plastic exudation is then thrown out, which forms adhesions with the serous membrane, and becomes intimately amalgamated with the fibrinous mass occupying the course of the wound, to which it has become closely adherent. The wound is in this way oblit- erated throughout its entire course by a fibrinous clot, and its lips are covered by a fibrinous disk, adherent to the pleura, to the lips of the wound, and to the plugging fibrinous clot. It bears a considerable resemblance to a large fibrinous nail, the stem occupying the course taken by the wounding instrument, and the head being flattened upon the lung, to which it closely adheres. Gentlemen, who can fail to see that the surgeon by emptying the pleura of the blood effused into it from the wounded vessels must prevent flatten- ing of the lung, so powerful a preventive of hemorrhage, and must likewise frustrate the formation of that plugging dot which I have been so care- fully describing to you ? Weigh well the fact, that by making an opening in the thoracic walls you excite violent efforts at coughing, which will be peculiarly apt to in- crease the hemorrhage, and to break down the plugging clot as fast as it forms. I have been reasoning upon the supposition that an attempt is made, by the operation for empyema, to clear the pleura of the clots by which it is filled. Let us now inquire whether it be possible to accomplish this object. I shall sum up in a few words the series of experiments by which M. Le- blanc and I attempted to elucidate the question. We made a small incision in the skin of a horse between the middle ribs; we carefully divided the tissues of the intercostal space, and when we reached the pleura, we opened it in such a way as to avoid the lung, and to limit the incision to some millimetres. By a stroke of the fleam, we then opened the jugular vein of the animal; and then, by means of a kind of funnel, the small end of which was placed in the pleura, and the other used to receive the product of the venesection, we introduced into the pleural cavity one hundred, two hundred, four hundred, or even as many as three thousand grammes of blood. Having introduced the blood, we closed the wound by means of a twisted suture. In place of transmitting the blood directly from the jugular vein into the pleura, we generally re- ceived it in a syringe, and before it had time to coagulate, we injected it into the pleural cavity. We also divided an intercostal artery, and allowed a certain quantity of blood to flow from it into the pleura. This experiment was performed on several horses. They were killed; some immediately after the operation, and others after an interval of one, two, twenty-four, forty-eight, and seventy-two hours, and of from six to ten days. Without a single exception, however short was the interval between the injection and the autopsy, we found the blood coagulated. So rapidly did coagulation take place, that when, in our experiments, we opened an intercostal artery and caused the blood to flow directly into the pleural cavity, making at the same time an opening in a more dependent part of the chest, hardly a drop of blood flowed out by it. The same thing took place when we injected from one to three kilogrammes of venous blood taken 634 TRAUMATIC EFFUSION OF BLOOD INTO CHEST: from the jugular vein, and, at the time of injection, in a perfectly liquid state. We repeated the following experiment several times. As soon as the injection was completed, we felled the animal by a blow on the head with a hammer; we then, without a moment's delay, opened the abdomen, ex- posing the diaphragm ; while the heart was still beating, and consequently while physiological life was still quite preserved, I opened the pleural cavity through the diaphragm, and found the blood in a clot. It was firmly coagulated, although the blood of the same horse taken at the same bleed- ing, but before the blood injected into the pleura and left exposed to the air in an evaporating vessel, was only partially coagulated. Let me add, that in cases in which the autopsy was made with the greatest possible celerity, not more than five minutes elapsed between injecting the blood into the pleura and ascertaining its condition there. Gentlemen, when we received at the same time, in two separate evapor- ating vessels, the blood from the vein of a healthy man, and the blood from the vein of a healthy horse, it was observed that the human blood coag- ulated much the most quickly. Now for the inferences from these facts. These conclusions you have already deduced. When blood is effused into the pleura, consequent upon a wound of the chest, coagulation takes place in a few minutes, so that to perform the operation for empyema with a view to remove the blood is as senseless as it is useless. Whether it be suction, the worst and most absurd of all the operations, or pumping out the blood - (a still more danger- ous proceeding, as it is a more forcible kind of suction)-whether simple tapping be resorted to, or whether an incision be made in an intercostal space, it will be impossible to withdraw the blood, on account of its coag- ulated condition. You will, gentlemen, nevertheless, hear it said by the most experienced surgeons, you will read in the works of the most accredited authors, that they have been able after wounds of the chest, to withdraw a great part of the sanguineous fluid by tapping, or by incision. The experiments of which I have given you an account were performed, as I have already told you, thirty years ago, by M. Leblanc and me. As you can well believe, they have been discussed and their results disputed. In the first place, it has been said that blood in contact with living parts, consequently at the same temperature it possessed when leaving the vein, does not coagulate, or at least coagulates more slowly than blood which has remained in a vessel ex- posed to the air, and the rapid coagulation which we described was abso- lutely denied, or at least otherwise explained. The experiments which M. Leblanc and I made upon the influence of temperature upon coagulation of blood taken from the vessels, experiments which have been repeated, and are at present no longer disputed, show that coagulation takes place most quickly when the blood is placed in a higher temperature. Thus, to give only a summary of our experiments: when we received the blood of a horse in ten evaporating vessels, and placed these vessels in fluids vary- ing in temperature from zero to 40 degrees, we ascertained that by main- taining the blood at zero, it remained fluid for several successive days, al- though it coagulated in less than two minutes when the evaporating saucer was kept in water at 40 degrees, and that the coagulation became slower and slower, in proportion as the temperature was lower. Matters do not proceed differently within the pleural cavity. The blood coagulates there in a very brief space of time, because it there finds a high temperature, and the slight amount of motion communicated to it by respiration only retards coagulation by a few minutes, if it retards it at all. PARACENTESIS. 635 Surgeons, then, have not properly understood what takes place. There is a confusion about the subject which I wish to dissipate. The clot which forms within the pleura does not differ much from that which forms in vases where the blood is by itself. Between the two, how- ever, there is a slight difference. In a vase, coagulation takes place more slowly ; consequently, the red globules being heavier have time to be pre- cipitated before the fibrin has contracted: the result is, that that which is called the buffy coat [couenne inflavimatoire] composed of fibrin and serum, is always more abundant, other things being equal, when the blood remains longest in a fluid state. The clot, on the contrary, coagulates in the mass, and without forming any buffy coat, when it coagulates very quickly: that is what takes place in the pleura. But after a very short time, the serosity imprisoned within the clot partly bursts forth, and, shaken up as it were by the movements of respiration, is always mixed with a great quantity of blood-globules: at the first glance, it has the appearance of fluid blood. There are two things then to be considered in cases of effusion of blood into the chest: there is the clot, which generally occupies the most depen- dent parts ; and there is the bloody serosity, which comports itself exactly like the serosity of a pleurisy. If the surgeon were to tap, he would be able to withdraw a large quantity of serosity deeply colored by the cruor; and might thus come to the conclusion that he had withdrawn fluid blood. The quantity of this sanguineous fluid may be still farther augmented by a circumstance which I ought to mention. The presence of some blood is not a cause of much irritation, as I shall forthwith be able to prove to you, but the lesion which has caused the sanguineous effusion is a source of considerably more mischief, and very usually leads to inflammation of the pleura and lung. Matters become much more serious when there is pneu- mothorax. In such a case, the serous effusion comes from two sources; viz., from the clot itself, which is the least abundant source, and from the inflamed pleura, whence it is impossible to calculate how much may be exuded. In any case, the fluid secreted by the irritated pleura continually in contact with the crassamentum will dissolve a large amount of blood- globules, so that if paracentesis were to be performed, it might be supposed that fluid blood was being withdrawn, whereas there is nothing evacuated but sanguineous serosity. We have seen, gentlemen, that making an opening into the chest, whether by tapping or by incision in the intercostal spaces, is a useless measure in the treatment of traumatic extravasation of blood : it would be easy for me to prove that it is, at the very least, injurious, and is frequently fatal. I have no difficulty in admitting that tapping, performed with the instru- ments and the precautions which are universally adopted in the present day, that is to say with a trocar fitted with the proper membranous valve, is, for the most part, a harmless operation; but there are exceptional cases, in which it gives rise to a circumscribed pleurisy, which cannot fail to be troublesome. Were there nothing in the pleural cavity but the serosity which had separated from the crassamentuny, it would hardly be worth while to tap, for that serosity would soon be absorbed. If the extravasated blood-in particular, if its traumatic cause-has given rise to pleurisy, with consecutive effusion, tapping may be useful; but under no other cir- cumstances can it prove beneficial. As to making an incision in an intercostal space, a proceeding I adopt in cases of purulent effusion, when the effusion has been reproduced after simple tapping, it cannot be otherwise than a very dangerous proceeding in traumatic extravasation of blood. I have said sufficiently often, that it must be useless, because the blood 636 TRAUMATIC EFFUSION OF BLOOD INTO CHEST: having coagulated, there is no possibility of the coagulum finding an exit by the opening, even were it infinitely larger than it is generally made. Not only is the incision useless, but is far from being exempt from dan- ger. However small it may be, it necessarily leads to the introduction of air into the pleural cavity, and this occurrence when repeated is certain to lead to pleurisy, and hydropneumothorax, affections of an exceedingly serious character.* The blood poured into the pleura putrefies; and it is easy to understand the risks consequent upon this occurrence. I have the most profound conviction that the majority of failures which surgeons for- merly had in treating wounds of the chest, were due to this perilous pro- ceeding, now, thank God, abandoned by the majority of practitioners. Our experiments have superabundantly demonstrated its peril. Those who still wish to try to evacuate blood extravasated into the pleural cavity, following in this respect the example of the illustrious Dupuytren, after the assassination of the Duke de Berry, are under the influence of three false ideas. They think that the blood remains fluid : they think that it irritates: and they think that it is absorbed with great difficulty. The experiments made by M. Leblanc and me demonstrate the falsity of these three suppositions. We have already seen that the blood coagulates at the moment it is ex- travasated ; and that we can withdraw, by tapping or incision, only the serum, without the crassamentum, a result which is really not worth the trouble. Let us now inquire whether the blood produces irritation. In our numer- ous experiments, when we killed a horse, four, six, or eight days after the injection of blood into the pleura, if, as sometimes happened, we found a clot, we never detected any traces of pleurisy. I grant, however, that ex- travasation of blood is not a perfectly harmless occurrence, and that it must somewhat irritate the serous membrane. More particularly I grant that it may predispose to pleurisy an individual who but for it would have escaped. Some months ago, a young man was practicing fencing with a friend : in an animated encounter, the knob of his adversary's foil was broken off without the occurrence being perceived; and a strong thrust penetrated the chest at the right arm-pit. There was neither external bleeding, nor sub- cutaneous ecchymosis, and, consequently, none of the vessels of the axillary region were injured. But scarcely had a few moments elapsed, when the wounded young man felt very acute pain in the region of the liver, exactly similar in character to that produced in the pelvis by that hemorrhage from the fimbriated extremity of the Fallopian tube which constitutes retro- uterine and peri-uterine hsematocele. All the symptoms quieted down during a few days of repose. The patient had no fever, and was able without fatigue to attend a horse-race a fortnight after he received the wound in the chest. But some days later, he experienced a feeling of unease, and had some cough. Under these cir- cumstances, I was summoned by my honorable friend Dr. Reis to meet him in consultation : we detected an extravasation of blood-not much in quan- tity-in the right pleura. This extravasation made rapid progress. It soon became so extensive as to suggest to me the propriety of considering * By experiments on animals, it is easy to satisfy oneself that the accidental ad- mission of air into the pleural cavity is perfectly harmless : but a repetition of the admission of air, even when the operation is set about with care, causes pleurisy. "When a permanent opening is made in the chest, pleurisy and hydrothorax are inevitable.-See the account of our experiments in the Journal de Medecine Veter- inaire, already cited. PARACENTESIS. 637 whether we ought not to resort to paracentesis. A third physician was associated with us in consultation; and the result of our meeting was an adjournment of the operation. A fortnight later-ten weeks after the acci- dent-the pleural effusion found a passage outwards by the bronchial tubes. In this way, the young man got rid of an enormous quantity of pus slightly tinged with blood, after which the expectoration diminished very gradually, and finally ceased four months subsequent to the accident. If the traumatic hemorrhage into the pleura may occasion a fluxionary determination, predisposing to pleurisy, will not the operation for empyema exert much more powerfully an evil influence on the state of the patient? We have seen, gentlemen, that the blood coagulates as soon as it is poured out in the pleural cavity ; that it there excites only a very moder- ate amount of irritation. It is now necessary to show you that it is absorbed with a rapidity so extraordinary as to be incredible, were not the fact demonstrated by experience in the most positive manner. When we injected into the chest of a horse 200 grammes of blood drawn from the vein, or when an intercostal artery was opened, and the blood allowed to flow into the pleural cavity, there were in the majority of cases no traces of it to be found after forty-eight hours, or at the most, only a little bloody serosity. Supposing that the effusion amounted to 500 grammes, only a small clot will be found at the end of three days : more than four-fifths of the fluid will have been absorbed. Even when the experiments were made with from one to three kilo- grammes of blood, more than half of the entire quantity was found to have disappeared in forty-eight hours: after three days, there only remained, as in the former case, a small clot and a little reddish serosity. Throughout our experiments, we did not in a single instance find the slightest trace of inflammation of the pleura. I grant that, perhaps, the pleura of a horse is more tolerant than the pleura bf a man : I admit also that, perhaps, the blood may be the temporary cause of inflammatory determination to the pleura; but still, from the cases and experiments which I have laid before you, am I not entitled to say that in cases of traumatic extravasation into the pleura, the surgeon ought to remain as a spectator ? Absolute rest, and very low diet, were probably the best means of promoting absorption. Wounds of the chest complicated with pleural hemorrhage are, however, sometimes, frightfully dangerous, irrespective of the loss of blood, a fact which our experiments do not fully explain. I must, therefore, add a few words to the remarks I have already made on this subject. The blood injected into the pleura does not there comport itself after the manner of a foreign body. It does not seem to irritate the serous mem- brane more than food irritates the stomach, than fecal matter irritates the colon, or than urine irritates the bladder. But we know that sometimes the urine does irritate the bladder : it does so when there is a change in its character. Affections of the bladder also often occasion changes in the urine; but on the other hand, an altered state of the urine may cause catarrh of the bladder. The case is similar in respect of blood extrava- sated into the pleura. If the wound of the chest give rise to an escape of air as well as of blood into the pleura, there will be an immediate change in the character of the blood, which will then act as a foreign body. When, in our experiments, we allowed the blood to accumulate in an evaporating vessel, and when some hours later, we introduced the coagu- lated blood into the pleural cavity, it putrefied there : and the animals sunk under formidable attacks of pleurisy. This experiment is an addi- tional proof of the dangers which attend the operation for empyema, when performed with a view to remove coagulation from the chest. 638 HYDATIDS OF THE LUNG. But if, in spite of the physician, blood and air make their appearance simultaneously in the pleural cavity, violent inflammation is kindled: it is then a duty to resort, with the least possible delay, to the operation for empyema-to inject the tincture of iodine. In a word, it is necessary to act in the same way that I have counselled you to proceed in formidable col- lections of pus, and in hydropneumothorax. LECTURE XXXIV. HYDATIDS OF THE LUNG. Hydatids of the Lung though rare are not so rare as Hydatids of the Pleura.-Diagnosis is exceedingly difficult.-Resemblance to Pulmonary Phthisis.-Possibility of Cure by Spontaneous Evacuation by the Bron- chial Tubes.-Reserve required both in respect of the Prognosis and Treatment. Gentlemen: The examples of hydatids of the lung given by Dr. Davaine in his beautiful work on the entozoa, are comparatively very few :* and if you make inquiries on the subject of your hospital teachers, you will find most of them admitting that they have never met with a case of this affection. Bricheteau, who specially devoted his attention to diseases of the chest, only saw two cases of it during a medical practice of more than forty years; and my honorable and learned colleague, Dr. Andral, has only recorded five cases. Professor Monneret has only met with a single instance, and that was detected on the dead body. For my part, I had likewise only seen a single case, till I met with that which I now propose to make the text of some remarks on this singular affection. You will recollect that the patient to whom I refer was a young man of seventeen years of age, who, about the end of December, 1861, became a patient in St. Agnes's Ward. On his admission, I found that he had acute general bronchitis, and that the right lung was most affected. From hear- ing on that side coarse mucous rales like gurgling, a prolonged expiratory sound, diminished resonance on percussion over the infraspinous fossa of the scapula, and finally Hippocratic deformity of the fingers, I was led to fear that the bronchitis was only symptomatic of tubercles. This hypothesis was all the more probable from the fact, that the patient was said to have been liable to take catarrhal affections every winter from the time he was six years old; and that it was added he had had, on different occasions, pro- fuse hmmoptysis. I nevertheless reserved my diagnosis, the acute catarrhal affection of the bronchial tubes masking the characteristic signs of the tuberculous affection. The acute symptoms having moderated, the fever having ceased, and the rales steadily diminishing, the respiratory sound in the right lung seemed to me to become more normal. Some days later, however, there was a return of the fever, particularly in the evening; and the young man complained of pains in his right side. On examining that side of the chest we found dulness on percussion in its two inferior thirds, * Davaine : Traits des Entozoaires de 1'homme et des animaux domestiques. 8vo. Paris: 1860. HYDATIDS OF THE LUNG. 639 absence of thoracic vibrations, and the presence of broncho-iegophony; these omens, which conjoined with marked oppression in the breathing, indicated the existence of pleuritic effusion complicated with bronchitis, and anew characterized by mucous rales, and muco-purulent expectoration. These local symptoms and the bad general state of the patient, led me to fear that new tubercular mischief was going on in the right lung, when all at once during the night between 18th and 19th January, he was seized with great difficulty of breathing, accompanied by a threatening of suffocation, and after some violent paroxysms of cough, he ejected by the mouth a great quantity of muco-purulent matter. This afforded him some transient relief: but renewed attacks of coughing induced renewed purulent vomiting. Next morning, I ascertained that the quantity which he had brought up was half a litre. The vomiting now described was followed by a great change in the symptoms. I thought that the effusions, the existence of which I had detected on the previous evening, had found an exit by an opening in a bronchial tube, and as there was no sign of hydropneumothorax, I sup- posed that there was very probably an encysted or interlobular pleurisy, because on attentively examining the contents of the spittoon, whitish shreds of false membrane were seen. When these shreds were carefully washed, they appeared white, opaque, thickish, torn at the edges. Notwithstand- ing the great rarity of such cases, I came to the conclusion that what we saw was the debris of an hydatid tumor of the lung. This view was estab- lished, beyond any doubt, to be correct, by a microscopical examination made by M. Charles Robin. For three days, the patient continued to eject fragments of false membrane and muco-purulent matter mixed with a little blood. The expectoration gradually diminished in quantity, the fever ceased, and day by day, there was an appreciable amelioration in the state of the patient. Very soon there was no dulness on percussion in the inferior and posterior part of the lung, expiration continuing, however, to be blowing in that situation, where coarse mucous rales were still audible. Convalescence advanced rapidly; and, all the local phenomena having disappeared, the young man left us quite cured, after two months' residence in hospital. The principal points in this interesting case may be thus summed up: the rational signs were those of pulmonary phthisis: the physical signs were doubtful: there was bronchitis and pleurisy: then, under the influence of the acute disease, a hydatid tumor, developed in the inflamed lung, be- came the seat of inflammation, an eliminative process began around it, and the patient ejected hydatid fragments mixed with a vast quantity of pus. Immediately consequent upon the ejection of a great quantity of muco-pur- ulent matter, auscultation revealed the existence of a cavity in the inferior third of the right lung, where blowing respiration could be heard. By de- grees this cavity disappeared, the normal respiratory murmur again became audible throughout the whole extent of the chest, and the general state of the patient became more and more satisfactory. I said that in all proba- bility the hydatid had its seat in the lung, because after the vomiting we could discover no signs of hydropneumothorax, which signs would certainly have existed had the tumor projected into the pleural cavity. Gentlemen, before commenting on this case, which is similar to others, and suggests considerations relative to the difficulties attending the diag- nosis of hydatids of the lung, the progress of the case, and the different modes of termination, let me, in passing, direct your attention to the semei- ology of that deformity of the fingers which we have observed in our patient. It is stated in the works of Hippocrates that the nails of phthisical sub- jects become contracted-tabidis ungues contrahuntur-and crooked-tabidis 640 HYDATIDS OF THE LUNG. ungues adunci. This clinical fact, though not denied, was forgotten, till 1832, when Dr. Pigeaux pointed it out anew. In the following year I pub- lished in the " Journal des Connaissances Medico-Chirurgicales " a paper on this subject, accompanied by a plate drawn by my pupil, Dr. Jardon; and now there is no physician ignorant of what is meant by the expression -"Hippocratic deformity of the fingers." This deformity consists in con- traction of the ungual phalanx, with enlargement and thickening of the digital pulp. Whilst the nail becomes curved towards the palm of the hand, the extremity of the finger assumes the form of the large end of a club, and sometimes, in enlarging, it flattens so as to resemble the head of a serpent. This deformity, generally, comes on by slow degrees; but, at other times, it is produced with great rapidity, the patients suffering pain from the change which is going on. The other phalanges do not undergo any change. In some persons the toes are the seat of a similar deformity; but, when it occurs in the toes, it is generally in a much less degree than in the fingers. Hippocratic deformity of the fingers is chiefly observed in persons who have reached the second or third stage of pulmonary phthisis: it is not met with in scrofulous subjects, and it seldom exists in patients affected with abdominal phthisis, unless they are likewise the subjects of pulmonary tubercle. It is also observed, as the older physicians stated, in individuals affected with non-tuberulous chronic diseases of the chest. Some years ago I ob- served it in a child whom 1 believed to be tuberculous, and in whom para- centesis of the chest, performed for an enormous pleuritic effusion, had left a fistula, by which for several months a large quantity of purulent serosity was discharged. This child grew up to adolescence, retaining the fistula: the chest had undergone considerable contraction, but I was never able to detect any signs of tubercle. In 1859 I had a female patient whom I twice tapped-the interval between the tappings being short-in a case of empy- ema following parturition, who retained a thoracic fistula for two years: this woman had Hippocratic deformity of the fingers, but I could not detect in her any sign of tubercle. I believe, then, that Hippocratic deformity of the fingers may be an accompaniment of chronic chest affections unconnected with phthisis. The two cases which I have narrated, and others which I could cite, show that it is liable to occur in diseases of the pleura: I have observed it in patients with bronchitis, with emphysema, and in others who had nothing more than nervous asthma: I have also seen it in patients with organic disease of the heart. It must be remembered, however, that it is principally in cases of phthisis that it is met with, and that the curving of the nail is the more marked the more advanced is the stage of phthisical disease. For this reason Hippocratic deformity of the fingers has some value as a diagnostic sign of phthisis. Gentlemen, excuse me for making this digression. In clinical studies facts, apparently the most insignificant, may have their importance, and so we ought not to neglect them. Let us now return to our subject-hydatids of the lung. The details into which I entered in reference to our patient of St. Agnes's Ward, have shown you the embarrassing nature of the diagnosis. The difficulty lies in the fact, that there is no special sign of hydatids of the lung. Study the cases which are recorded in scientific works, and you will perceive that in a great number, perhaps in the majority of them, the mor- bid phenomena are sometimes dependent on pleuritic effusion, and some- times upon pulmonary phthisis. Of course, when the hydatids, or fragments of hydatids, have been expectorated, there is no room for doubt as to the HYDATIDS OF THE LUNG. 641 nature of the case; but there will still be an uncertainty as to the precise seat of the tumor: it will be a question whether it is situated in the paren- chyma of the lung or in the pleural cavity, or whether the hydatids have not come from the liver by way of the lungs. Intrathoracic hydatid tumors occur much more frequently in the paren- chyma of the lung than in the pleural cavity, as has been shown by M. Davaine by an analysis of cases collected by him. This opinion had been previously enunciated by Laennec, and is likewise that of Professor J. Cruveilhier. By simply reasoning from analogy, moreover, the same con- clusion might have been come to; for it is in parenchymatous organs, such as the liver, spleen, and kidneys, and in the thickness of muscular masses, that hydatids are generally, or indeed nearly always, developed. The res- piratory apparatus is no exception to this general rule: and M. Davaine believes that a great many alleged hydatids of the pleura, are really hydatids of the lung which have fallen from their original situation into the cavity of the pleura. It may likewise happen, that tumors situated near the periphery of the lung, as they slowly develop themselves at the edge of that organ, may become detached, to a greater or less extent, from the pulmonary pleura, which they push over to the costal pleura, in such a manner that the hydatid pouch seems to be placed in the serous cavity, although in reality it is wholly external to it. Such seems to have been the state of matters in a case reported by Dupuytren and Geoffrey, and designated by them-double cyst of the pleura. In that case, it is stated, that the patient had had numerous attacks of haemoptysis, which one can hardly understand, unless the cyst had in the first instance occupied the pulmonary parenchyma, as we know that haemoptysis is a very common symptom of diseases of the lung, while it never supervenes in affections of the pleura. Haemoptysis, moreover, has been remarked to have occurred in nearly all the cases of pulmonary hydatids. A man whose case has been published in the Bulletins de la Societe Anatomique by M. Husson, expectorated hydatids upon fifteen different occasions, and each time the occurrence was preceded by spitting of blood. He never had any of the rational or physical signs of pulmonary tuberculization; and his general health was satisfactory. Gentlemen, when hydatid tumors seated near the periphery of the pul- monary parenchyma are slowly developed in the direction of the pleura, there can be no symptoms except those which accompany more or less pleuritic effusion, or are caused by the squeezing of the lung into the verte- bral hollow. You can understand, however, that these symptoms are more or less serious, and that when they are caused by a double cyst, as in the case narrated by Dupuytren and Geoffrey, the embarrassment in the breath- ing may proceed to such an extent that the patients are carried off by suf- focative fits. But when a hydatid tumor of the lung bursts suddenly into the pleural cavity, the symptoms are very much more serious, as a subacute pleurisy is set up, and when the bursting is both into the pleura and the bronchial tubes, there is produced hydropneumothorax, as happened in the follow- ing case, recorded by Dr. Mercier in the Bulletins de la Societe Anatomique. A man, thirty-eight years of age, subject for years to frequent haemoptysis, although he presented no other sign of tubercular disease at the summit of the lung, was suddenly seized with acute pain in the right side: on exam- ining the chest, hydropneumothorax was discovered: the patient sank rapidly. At the autopsy, there was found in the pleural cavity, a hydatid floating in the effused fluid : in the part of the lobe of the lung correspond- ing to the interlobular cleft, there was an excavation in the parenchyma VOL. I.-41 642 HYDATIDS OF THE LUNG. of the organ, and in the same situation was observed an ulcerated bron- chial tube. It is evident, or at least very probable, that in this case, the process of elimination going on simultaneously in the bronchial tubes and pleura, led to perforation of the lung, and so to hydropneumothorax. The attacks of haemoptysis which occurred during life, the discovery after death of an ex- cavation in the parenchyma of the lung still containing the hydatid, seemed to point out clearly the seat of the affection. However, inasmuch as the exca- vation was situated in the interlobular fissure, it may be asked whether the pouch was not originally formed in that fissure, whence it had invaded and excavated the pulmonary parenchyma: and on comparing this case with cases in which hydatids unquestionably occupied the lung itself-in con- sidering, as I have just been saying, that it is generally in parenchymatous organs that these entozoa become developed, it was justifiable, arguing from the general to the particular, to conclude, that in this case the original seat of the tumor was really that which' the examination of the dead body enabled us to assign to it. This case may give you an idea of the difficulty which there is some- times of determining in the dead body the precise seat of an hydatid of the lung, when the tumor, not being situated in the interior of the parenchyma, has burst at the surface of the organ. I need not say that the difficulty will be infinitely greater when we make our examination in a living patient. However, when the radical cure takes place, after the ejection of hydatids by expectoration, the physician may conclude that the hydatids occupied the substance of the lung, the nature of the affection being shown by the discharge from the bronchial tubes; and when a hydropneumothorax is produced, it may be presumed, not only that the hydatids are situated in the pleural cavity, but also, that they occupy a position near the periphery of the lung. Sometimes, the hydatids are not inclosed in an adventitious cyst; and at other times, the containing cysts are exceedingly thin, a circumstance which well explains the facility with which they may find an exit by the bron- chial tubes, when these canals are opened by ulceration. This was pointed out by M. Houel in a report which he read to the Anatomical Society upon the occasion of M. Pinault communicating a case of pulmonary hydatids. The absence of the adventitious cyst, or the extreme tenuity of the envelop by which the cyst is constituted, likewise explains how hydatid tumors of the lung may become ruptured under the influence of an inflammatory affection of the respiratory apparatus, as occurred in the case of our patient of St. Agnes's Ward. Gentlemen, from M. Davaine's statistical researches, it appears that it is much more unusual to meet with several hydatid tumors in a single lung, than a single hydatid tumor in each lung; but it is still more common to find a single hydatid in only one lung, and in that case, it is generally in the right lung-usually in the inferior, but sometimes in the superior, lobe. The much greater frequency of hydatids in the inferior lobe of the right lung, considered in connection with the extreme frequency of these entozoa in the liver, has led to the supposition that, in a certain number of cases, the intrathoracic hydatids have passed from the liver into the chest. There have now been recorded numerous cases in which this passage of hydatids from the liver into the thorax has taken place. In 1856, Dr. Dolbeau called the attention of physicians to the tendency which* large * Dolbeau : Etudes stir les grands Kystes de la surface eunvexe du Foie. Thfese de Paris, 1856. HYDATIDS OF THE LUNG. 643 cysts of the convex surface of the liver have thus to invade the chest, pressing the diaphragm against the lung, at the same time depressing the liver, and so gaining the epigastric region. The invasion of the thoracic cavity by these cysts may be so great, that the lung, packed into the cla- vicular region, and into the vertebral hollow, is reduced to a third, or even, it may be, to a fourth of its normal volume. You can understand how such an invasion of the chest by an abdominal tumor, cannot take place without the diaphragm becoming exceedingly attenuated. This is what takes place: the attenuated diaphragm contracts adhesions with the hydatid pouch, which is consequently dragged up in the ascending movement. The result of this is, that when it is wished to determine the nature of the affection with which we have to do, we may possibly find nothing more than signs of a pleuritic effusion-absolute dulness of a greater or less extent of the lower part of the chest, absence of thoracic vibration, absence of vesicular murmur, absence of blowing and segophony, the results of the displacement of organs, and crushing up of the lung, the place of which is occupied by a liquid tumor. The progress of the disease, and the thoracic deformity (a deformity which extends to the region of the liver, where it presents a pecu- liarly characteristic aspect), furnish the only elements of diagnosis. The slow unobtrusive inflammation which has caused the formation of the adhesions between the hepatic cyst and the diaphragm, may, extend- ing, in virtue of contiguity, to the pleura and the lung, produce similar adhesions between the lung, the pleura, the diaphragm, and the tumor, which adhesions conduce to the favorable termination of the disease. If- as occurs in a few exceptional cases-adhesions do not form between the hydatid pouch and the lung, the pouch opens, through a perforation of the diaphragm, into the pleural cavity, occasioning an almost invariably mortal pleurisy. But if the adhesions are such that the lung, the pleura, the dia- phragm, and the cyst, are intimately united, the tumor, which ultimately always bursts, opens into the cavity it has dug for itself in the pulmonary parenchyma, and discharges by the bronchial tubes. A great number of cases of this character have now been published ; and, among other places, you will find them in the thesis of Dr. Cadet-Gassicourt,* and in the memoir of Dr. E. Leudet (of Rouen).f Bricheteau, setting forth all the interest which attaches to this subject, pointed out the propitious manner of evacuating hydatid tumors by the bronchial tubes.ji In the case of a patient whom he saw with Professor Natalis, Guillot states, that immediately after the patient had expectorated matter containing the debris of hydatids, there was detected, by auscultation, a cavity excavated both in the pulmonary parenchyma and in the liver; and which was char- acteristically indicated by amphoric blowing and pectoriloquy. That the liver was the seat of the tumor was sufficiently shown by the expectoration being constituted by a yellow fluid which assumed the color of verdigris when treated by nitric acid. At the time of bringing it up the patient felt a very marked saline taste in the mouth, due probably to the chloride of sodium, which chemical analysis has shown to exist in hydatid cysts. This fluid, taking a yellow color from the bile, has also sometimes a chocolate-brown hue derived from the coloring matter of the blood, and * Cadet-Gassicourt: Recherches sur la Rupture des Kystes Hydatiques du Foie a travers la paroi abdominale et dans les organes voisins. These de doctorat, Paris, 1856. f Leudet: Memoire sur le Traitement des Kystes Hydatiques du Foie, lu a la Societe Medicale des Hopitaux. [Archives Generales de Medecme, for January and February, I860.] J Bricheteau : in the Revue MSdico-Chirurgicale for 1852. 644 HYDATIDS OF THE LUNG. also from microscopic hepatic cells. These facts which have served as the basis of Bricheteau's work-a work to which I refer you-were obtained in his hospital practice, and he has added to them others, quoted from the curious memoir of Hebreard, formerly a physician of the Bicetre. But what I have to say on this subject, will be more in place when I come to speak of cysts of the liver: I therefore defer to another occasion some re- marks required to complete my account of this subject. I shall only add that the thesis of Dr. Cadet-Gassicourt has given us new means of diag- nosing intrathoracic cysts, a very important matter for clinical physicians. Before concluding, I must succinctly mention a case published by Dr. Vigla.* The patient was a man, aged thirty-two years, who, consequent upon a violent contusion produced by the kick of a bull on the right side of the chest, complained of pain in the right hypochondrium, and an oppression of the breathing, which from the date of the accident, fifteen months pre- viously, had been constantly increasing. For the preceding five months, the dyspnoea had been so considerable, that the patient had been obliged to give up his employment. He had little or no cough, and no expectoration: he had never had haemoptysis: although he had in a marked manner the symptoms of anaemia, he complained of no organic suffering, except that of which the respiratory organs seemed to be the seat; and he stated that the pulmonary symptoms had never been accompanied by fever. The intense pain of which he complained seemed to be limited to a small space under the right mamma. The oppression of the breathing, which was continuous, became excessive when he walked, or even after the exer- tion of speaking for some time: he could not lie on the left side, and gen- erally sat when in bed. On examining the chest, it was observed that there was a much greater development of the right than of the left side, and that anteriorly the right side was very much arched in appearance: there was distension of the intercostal spaces, which projected at least as much as the ribs. On the right side also, the normal resonance was com- pletely replaced by absolute dulness, which extended from the second in- tercostal space to the umbilicus, measuring-taking a line parallel to the sternum-28 centimetres, and-transversely-crossing the median line in such a manner that the space occupied by it was circumscribed below by a line, which after passing beyond the navel, proceeded in an oblique direction under the left axilla; and above, by a line which, following the upper edge of the second rib, passed over the sternum at three centimetres below the bifurcation of that bone, and proceeded by a curve to rejoin the lower line under the left axilla. Thus, it occupied the whole of the right side of the chest, encroaching a little on the left side. Applying the hand to this side, and at the same time requesting the patient to speak, it was as- certained that an entire absence of thoracic vibration existed; and on apply- ing the ear, there wals heard neither vesicular murmur, nor any anomalous sound in front, although posteriorly, the respiratory sound was exaggerated in the three superior fourths of the right side, as it was also in the left side. There was heard, moreover, on the right side, amphoric resonance of the voice, and even respiratory murmur, like that heard in certain pleuritic effusions, unaccompanied by blowing or aegophony. No lesion of the pulmonary parenchyma, as is justly observed by Dr. Vigla, seems capable of producing similar deformity of the chest. Nor was there any ground for entertaining the idea that there was hydrothorax; for * Vigla : sur les Hydatides de la cavite thoracique. [Archives Gener- ales de Medecine, for September and November, 1855. Vol. ii of fifth series.] HYDATIDS OF THE LUNG. 645 it would be difficult to believe that an encysted pleuritic effusion could be distributed so unequally and so irregularly as to respect the first intercostal space, the three superior and posterior fourths of the right side of the thor- acic cavity, while it invaded the left side, and pushed the diaphragm as far down as the umbilicus. The hypothesis that there existed a solid tumor-a cancer, an aneurism of the aorta or of one of its principal branches-was un- tenable. In the first place, a solid tumor would transmit the respiratory and cardiac sounds, which were entirely absent in this case: and then again, a cancerous tumor, the only tumor which could take so large a development, could not have been formed without producing general cachectic symptoms. Dull and deepseated fluctuation was perceptible, and furnished a sign, which, in conjunction with others, justified the presumption that there was a hydatid cyst. An exploratory puncture made by M. Monod, surgeon to the Maison de Sante, proved this diagnosis to be correct. The fluid which issued from the capillary canula of the trocar was clear as water from the crystal spring: it produced no change on litmus-paper, and no albuminous precipitate when treated by nitric acid or heat. Tapping, consequently, was performed with a larger trocar, when 2450 grammes of fluid similar to that originally with- drawn were evacuated. That portion of this fluid which flowed last from the canula, contained the shreds of transparent membrane, which M. Charles Robin found on examination to be the debris of hydatids. A solution of iodine was injected. Thirty-seven days after the operation -fifty-one days after his entering the Maison de Sante-the patient asked and received permission to leave, that he might resume his employment. Eleven months afterwards, when M. Vigla saw him, the cure was as com- plete as possible. Gentlemen, let me say a word to you on the great value of that peculiar arching of the thorax, observed in the case of which I have just given you an abridged history. It is a diagnostic sign full of meaning, and is in itself sufficient to justify an exploratory puncture such as M. Vigla practiced in his case. This form of arching of the chest, so very peculiar, enabled me so far back as 1848, to diagnose an intrathoracic hydatid tumor in a girl seven years old. This little girl presented the general appearance of a phthisical subject. For a long time, she had had cough and oppression of the breathing. Her emaciation was extreme. On examining the chest, I found complete dul- ness on percussion, and an absence of thoracic vibrations : there was a glob- ular projection of the thorax, the maximum of which corresponded with the sixth and seventh ribs. As there had been no hemorrhage, and as auscul- tation did not disclose any lesion of the upper parts of the lungs, I proposed to tap the chest. I was not allowed to do so: and the child died some weeks after my visit. Gentlemen, the clinical history of hydatid cysts of the lung is far from being complete. The insidious commencement, the sometimes slow, and at other times rapid progress of the affection, our almost complete ignorance of its etiology, sufficiently proclaim the difficulty of the subject. In the majority of cases, the nature of the affection has been mistaken, and very rarely even suspected during the life of the patients, so that for a long period the only data which we had in relation to it were those furnished by pathological anatomy. These data, however, were important, and such as to throw light on the manner of forming a diagnosis on the living subject. They informed the physician, for example, that he might meet with hyda- tids in the lung, but that they seldom if ever existed in the pleura: they told him that hydatids of the liver might pass from the liver into the thor- 646 HYDATIDS OF THE LUNG. acic cavity: that the existence of hydatids in the chest generally coincided with their presence in other organs, particularly in the liver, and that their favorite locality is the right lung. Pathological anatomy has also taught us that pulmonary hydatids, of which generally there is only one found in the same lung, may, within the parenchyma of the lung, become as large as the head of an adult; that their adventitious envelope may either be very thin or entirely wanting; that an acute inflammation of the lung may cause them to burst, either into the pleural cavity where they produce the symptoms of hydrothorax, or into the bronchial tubes, in which case they may be expectorated either in shreds, or in their totality. Pathological anatomy has shown us that these vast pulmonary and hepatic warrens communicate by one large diaphrag- matic fistula. In these facts, there is enough to lead us to suspect in some cases, and to affirm in others, that our patients have pulmonary hydatids. An attentive examination of the other organs, and the progress of the affec- tion, ought to enable us to bring together all the probabilities in such a manner as to determine the original seat of the affection which we suppose to exist. To Hebreard and Bricheteau, and MM. Vigla, Cadet-Gassicourt, and Davaine, belong a large share of the merit, which I am pleased to acknowl- edge, of elucidating this important question of the diagnosis of hydatids of the lung. We may suspect the existence of hydatids of the lung, if, along with the coexistence of certain symptoms, we find that peculiar deformity of the chest of which I have been speaking. When once the existence of the affection has been made out, it is then necessary to try to determine which is the probable original seat of the entozoa. In general, patients affected with hydatids of the lung, present many of the rational aud physical signs of phthisis or chronic pleurisy. In fact, the majority of this class of patients will tell you that they have been sub- ject for a long period to haemoptysis, more or less profuse, and more or less frequent, as well as to oppression of the breathing. You will hear rales disseminated over the chest, and sometimes you will find dulness at one or both summits, when tubercles will coexist with the hydatids. But inde- pendently of this exceptional complication, the attentive study of the prog- ress of the affection, the rational explanation of some of the symptoms, will enable you to reject the hypothesis that there is tubercular phthisis, when, for example, there is no disease of the summits, as in the case observed by M. Husson: the haemoptysis in such circumstances will then probably have no other cause than the continuous irritation excited by the presence of a foreign body, which will frequently occupy the middle, and still more commonly the lower, lobe of the lung. The general condition of the patient, his age, and the progress of the affection, will aid your diagnosis; and if you have had occasion to suspect the presence of hydatids in the liver, or in any other organ, you will be entitled to conclude that the pulmonary parenchyma is itself their seat. Again, attention is not directed to hydatids of the lung till they have attained a great size, when they are liable to be mistaken for several descriptions of encysted and interlobular pleurisy, as occurred in the case of the young man, our patient of St. Agnes's Ward. However, when, on examining a patient, you find a globular deformity of the chest of limited extent, the probability of the case being one of encysted hydatid is greatly strengthened: sooner or later, the progress of the affection, which is very different from that of pleurisy, and particularly the expectoration of hyda- tids, when it occurs, will remove all doubts. You will perhaps be justified, HYDATIDS OF THE LUNG. 647 even in cases in which this valuable diagnostic occurrence does not take place, to suppose that there are hydatids, when you see sudden symptoms of inflammation of the pleura, while at the same time there is flattening of the globular tumor, because there will then be ground to suppose that the flattening is consequent upon rupture of the hydatid pouch into the pleural cavity. This probably correct diagnosis will attain almost a certainty of being correct, if symptoms of acute pleurisy come to be added to the signs of hydropneumothorax. In such a case, ulceration, in virtue of which the hydatid has emerged into the pleura, has likewise, at the same time impli- cated a bronchial tube. I have said that it is needless to insist on the fact, so palpably evident, that when the debris of hydatids has been discovered in the expectoration, there can be no possible doubt as to the nature of the case. There will still remain some uncertainty as to the original seat of the hydatids. This is a point in diagnosis which has to be elucidated. Beyond all doubt, hydatid cysts have been found in the pleural cavity. M. Vigla's case, two similar cases narrated in his paper, furnish additional proof of this, up to a certain point. As for myself, I accept, with every- body else, the existence of these pleural cysts. But if an attentive analysis and a careful study be made of the cases, there will be found reason to believe that hydatids of the lung, which have fallen into the pleural cavity, have often been mistaken for pleural hydatids. This, you remem- ber, occurred in the case reported by Dupuytren and Geoffrey. Even M. Vigla's case is very open to discussion from this point of view, because as the patient fortunately recovered, there was no necroscopic examination to verify the diagnosis. Besides, if we consider, as I remarked at the beginning of this lecture, that hydatids generally develop themselves in parenchymatous organs-the liver, spleen, kidneys, and ovaries-we are led to conclude that the lungs form no exception to the general law, and that acephalocysts are much more frequently met with in the lungs, than in the pleura. Dr. Davaine, whom every one admits to be an authority on this subject, is quite convinced that hydatids of the pleura are very rare. The result of his laborious researches is to the effect, that in twenty-five cases of hydatids which he examined, there was only one in which evidence existed of the primitive development of the hydatids having been in the pleural cavity. The diagnosis of the precise seat of intrapleural hydatid cysts is rendered all the more difficult by the circumstance, that hydatids of the convex sur- face of the liver may invade the chest, either pushing up the diaphragm without perforating it; or, without bursting, they may make a passage for themselves through the distended attenuated fibres of that muscle. It may be asked, if this be not what happened in M. Vigla's case-whether his case be not similar to that reported by Professor J. Cruveilhier,* in which a hydatid cyst of the liver, which had penetrated into the pleural cavity, was evacuated by paracentesis of the chest, a cure taking place as in M. Vigla's patient. I am aware, however, as I have been careful to tell you, that cases of this description are of exceedingly rare occurrence : that very commonly, hydatids of the liver rupture, and thereby cause a rapidly mortal pleurisy ; or, as is still more usual, adhesions form between the diaphragm, pleura, and lung, so that when the hydatids open into the cavity which they have formed by burrowing in the pulmonary parenchyma, they empty themselves into the bronchial tubes. * Cruveilhier: Dictionnaire de Medecine et de Chirurgie en 15 volumes; article, Acephalocystes: Paris, 1829. 648 HYDATIDS OF THE LUNG. When the latter occurrence takes place, just as in that which I pointed out as happening in hydatids of the lung, the elements for forming an opinion possess an almost absolute degree of certainty. Apart from the circumstance of fragments of hydatids, or entire hydatids, being found mixed up with the expectorated matter, that matter presents peculiar and unmistakable characters. In it we find a yellow, thick, oily fluid, which, on the addition of nitric acid, assumes the color of verdigris, evidently dependent on the presence of the coloring principles of the bile. The fluid has sometimes a chocolate-brown color, due to an admixture of a certain quantity of blood. Then, again, there is a diminution of the tumor in the right hypochondrium caused by the increased bulk of the liver; and the hitherto impeded movements of the diaphragm become more easy. Finally, gurgling, amphoric blowing, and vocal resonance heard on applying the ear or the stethoscope to the situation formerly occupied by the tumor, show that a cavity exists which is evidently excavated partly in the lung and partly in the liver. Gentlemen, when you have diagnosed an intrathoracic hydatid, be very reserved as to the prognosis. While you have a right to hope that all may go on favorably, that the malady may reach a happy issue by the unaided efforts of nature, and through the mechanism which I have explained to you at such length, you must not forget that the work of elimination, though in itself favorable, is not unattended by danger. At its commence- ment, it may occasion suffocative paroxysms: the presence in the air- passages of the hydatids and of fluids which irritate the larynx, the trachea, and the bronchial mucous membrane, may occasion fits of coughing, which in their turn may lead to mortal hemorrhages, an occurrence of which an example has been reported by Dr. Pillon. You have to dread hydro- pneumothorax, and its disastrous consequences. You have also to dread asphyxia, a consequence of respiration being interfered with by the tumor attaining so large a size as to compress the lung: this happens not only in cases like that of Dupuytren and Geoffrey, in which the intrathoracic tumor was double, but likewise when there is only a hydatid on one side. When these unfavorable circumstances do not exist, and when the hydatids find their way out of the body by the bronchial tubes, you may not only hope for recovery, but also for an early cure. The inflammatory symptoms which attend the process of elimination cease, the fever subsides, the appetite returns, and at the end of some weeks, there may be perhaps a complete restoration to health. Ought there to be any active interference on the part of the physician with intrathoracic hydatids? It is most prudent to abstain from such interference. Here, as in many other circumstances, we must know how to wait, while we attentively watch the patient, seeking to moderate inflam- mation and sustain the vital powers. So far am I disposed to go in advising extreme caution, that I even recommend you to abstain from exploratory punctures, which there is a temptation to make, with a view to elucidate the uncertainty of the diag- nosis. These punctures may prove fatal, if adhesions have not been formed between the tumor and the walls of the chest, by causing effusion into the pleura, the dangers of which occurrence I have pointed out to you. Now, it is impossible for the most experienced physician to affirm that such adhesions exist. When circumstances peremptorily compel you to inter- fere so as to give exit to the fluids, the first indication is to excite adhesive inflammation, the existence of which is absolutely necessary: this, however, cannot be brought about, unless the tumor is in contact with the thoracic walls, and unless there is no intervening portion of lung. This indication PULMONARY ABSCESSES, ETC. 649 will be fulfilled by making numerous acupunctures, and repeating them on several successive days.' When adhesion has taken place, the pouch may be emptied by tapping it with a bistoury or large trocar, after which it has to be injected with a solution of iodine. This is a mode of treatment exactly similar to that which I adopt for the cure of hydatid cysts of the liver, a subject upon which I hold myself in reserve till an opportunity occur, when I shall fully go into it. I would now only add, in conclusion, that I have never practiced this method for the cure of hydatids of the lung, that I do not know whether it ever has been so employed ; and consequently I cannot say what might be the re- sults of having recourse to it. LECTURE XXXV. PULMONARY ABSCESSES AND PERIPNEUMONIC VOMICAE. Rare affections, if we exclude from the category Tubercular Vomicae and Metastatic Abscesses.-Most frequent in Children, in whom they are the result of Lobular Pneumonia.-Diagnosis of Peripneumonia Vomicae is Difficult.-They may be confounded with Pleural Abscesses. Gentlemen : At the close of my last lecture, I showed you the lungs of two patients who died in our wards of acute pneumonia. At one of the autopsies from which these lungs were obtained, you may have seen that an immense pouch of pus occupied the anterior and lower portions of the superior lobe of the left lung. This cavity was large enough to hold a large egg of a hen : it was divided by incomplete partitions into chambers communicating with one another: the walls of the cavity were formed by gray indurated pulmonary parenchyma. The cavity communicated with the pleural cavity by a large opening, shaped like a button-hole, situated at the anterior margin of this pulmonary lobe, and probably measuring about two centimetres in length. In every other situation, the parenchyma of the lung seemed to be healthy, and to present no trace of tubercle. In the cavity, there was no trace of anything like tubercular matter: and there was not the slightest exhalation of a gangrenous odor. The corre- sponding pleural cavity was filled with a great quantity of creamy, inodor- ous, white pus. The surface of the visceral and parietal serous membrane was covered, in the two lower thirds, with a layer of matter, pultaceous, pseudo-membranous, thick, and of a greenish-zwhite color. The lung ad- hered closely to the walls of the chest along the vertebral column, as far down as the diaphragm ; but on dragging the adhesions, they easily gave way, except near the diaphragm, where they resisted so much that it was necessary to remove the diaphragm with the lung. The left lung, one- third less voluminous than the right, had its superir lobe flattened upon itself, and applied along the spine. An attempt to inflate it failed, in con- sequence of the air escaping by the opening into the cavity of which I have spoken. There was nothing abnormal in the condition of the right lung, except- ing some old adhesions, which did not offer much resistance. 650 PULMONARY ABSCESSES AND At the autopsy of the other case, you also saw a large purulent cavity in the left lung, but it was in a less advanced state, and in fact was only be- ginning to form. It was, moreover, the result of a circumscribed or partial peripneumonia, whereas in the other case, it existed in the midst of a lobe inflamed throughout its entire extent. The pulmonary tissue presented, in fact, the consistence of hepatic tissue. The two lobes of the left lung were completely involved, and had a very manifest gray color: when an incision was made in the condensed paren- chyma of the lung, a great quantity of a frothy grayish sanies oozed out from the incised surface. The tissue was easily torn by the pressure of the finger: at the superior and posterior part of the inferior lobe, was situated the purulent cavity of which I have been speaking. It was as large as the abscess we met with in our first autopsy: it was quite full of putrilaginous matter of a lateritious appearance, and only separated from the interlobular fissure by a very thin plate of pulmonary tissue. The examination was made with great care, and without any violence, so that it did not seem probable that there had been any accidental breaking up of tissue by the pressure of the hand of the pupil who made the necropsy; still, I must tell you that I have my doubts on this point. These two cases, gentlemen, are examples of what have been called vomicoe -abscesses of the lung: they are phlegmonous abscesses, very different from the purulent collections met with in tuberculous subjects, very different also from the abscesses termed metastatic, which we meet with in the bodies of persons who have been carried off by purulent infection, and which are char- acteristic of the purulent diathesis. These non-tuberculous, non-metastatic, purely inflammatory vomicae are very rare lesions in adults. I make this limitation, because in young children they occur very frequently. On this point, I fully concur with recent clinical observers who have written on the pneumonia of children. In a certain restricted sense, however, the general rule is likewise applicable to children ; for it is only in lobular pneumonia that pulmonary abscesses are met with, and lobular is a very different affection from lobar pneumonia. Pulmonary abscesses in children sometimes occur disseminated in very small number throughout the pulmonary parenchyma : at other times, they are placed so closely together as to resemble myriads of tubercles. They are met with least frequently under the latter aspect. When they are very few in number, they either form small pouches on the surface of the lung, pro- ducing prominences under the pleura ; or, having emptied themselves by the bronchial tubes, they contain only air; or possibly, they may contain a mixture of air and pus. In these different states, it is difficult to say whether the pouch has been formed by a suppurating lobule, or by dilata- tion of the extremity of a bronchial tube terminating in a lobule, the cells of which have been ruptured : in the latter case, it would be merely a variety of vesicular emphysema. But when the abscesses are very numerous, there is something special in the appearance of the lung which requires to be ac- curately described. Lobular pneumonia then becomes aggregated or pseudo-lobar: in other words, the inflamed lobules unite in large masses, invading, it may be, nearly or quite, the whole of a lobe, as in the pneumonia of adults. Two young children were attacked with acute pneumonia. The elder was taken to the Hopital des Enfans Malades, where he died after a resi- dence of a few days: the other, suckled by his mother, was taken to the Hopital Necker, where he was placed under my care in St. Julia's Ward. The existence of pneumonia was unquestionable: but it seemed to be lim- ited to the left side. There was heard on that side a very decided blowing PERIPNEUMONIC VOMIC2E. 651 sound, and also a considerable degree of reverberation of the cry. There was a rather coarse subcrepitant rale, and a little obscurity of the breath- sound. These signs continued to the last. On the right side, the respira- tion was feeble; and two days before death, we began to hear some sub- crepitant rales unmingled with any blowing. There continued, however, ardent fever, and great oppression of the breathing. At the autopsy, when the lungs were placed upon the anatomical table, a multitude of yellowish-white spots were seen shining through the pleura, forming a striking contrast to the red color of the hepatized parenchyma, which seemed to be stuffed with tubercles, some in a crude state and others in a state of softening. On making a clean cut through a large mass of lung, a similar aspect was presented, with this difference, that the appear- ance of the parts was to a slight extent modified by the gushing of pus from the incised surfaces. By letting a small stream of water fall on the tissues thus altered, the water carried away some of the pus, and so disclosed to view an irregular cavity with imperfectly defined edges. As the little stream of water did not wash away the whole of the purulent matter, there remained a cavity not so well defined as before, and a very soft mass ad- herent to the parenchyma. Finally, among the portions of lung which presented at a first glance this general appearance of tubercles, there were some portions from which, although very friable, the water detached noth- ing. All around this, the parenchyma was hepatized. A very little attention was sufficient to dispel the idea of the existence of tubercles. We had evidently to do with lobular pneumonia in four degrees : there was red hepatization, affecting the great mass of the lobules ; light-colored hepatization, corresponding to the third degree of pneumonia in the adult; partial softening of the lobules, which had passed to light- colored hepatization; and, finally, complete softening of these same lobules- true peripneumonic vomicse. It was a somewhat remarkable fact, that these four degrees were observed in the left lung, which was the first as well as the most violently attacked; while the right lung, not attacked till two or three days before death, pre- sented only the first two degrees. During the autopsy, I took care to point out how much these lesions differed from tubercles; and to remark, that one could not fail to recognize in the inflamed lobules the identical forms coexisting sometimes in entire lobes of the lungs of an adult. Besides, the exceedingly acute character of the disease would indicate that it was a pure pneumonia; and although it be quite true that sometimes I have seen acute attacks of pneumonia prove fatal, in a few days, in chil- dren who had hardly ever previously coughed, and have, at the autopsy, found the lungs full of tubercles in different stages, it is not less true that pathological anatomy furnishes means of distinguishing cases of pneumonia complicated with tubercles, from cases in which the pulmonary tissue is studded with abscesses. Quite recently, I showed to all of you in this am- phitheatre the lungs of an infant at the breast, in which were thousands of little pouches filled with perfectly homogeneous pus. The infant had only been ill for a fortnight. I now return to the consideration of what takes place in the adult. In adults, as I have already said, non-tuberculous, non-metastatic, purely in- flammatory vomieje are exceedingly rare; indeed, they are so rare, that during my first twenty-five years as an hospital physician, I never met with a case of this description. By one of those strange coincidences, however, which sometimes occur in practice, the two cases which we have seen to- gether presented themselves to my notice during one week ; and one of the 652 PULMONARY ABSCESSES AND cases has left some doubts in my mind. This lesion is so rare, that Laennec- whose authority is of great weight in such a question-affirms that in open- ing the bodies of several hundred persons who had died of peripneumonia during a period of twenty years, he had only five times met with abscesses in inflamed lungs. " Moreover," adds the immortal author of the Traite de 1'Auscultation Mediate, " they (the abscesses) were inconsiderable, few in number, and scattered throughout the lungs, which presented the third degree of inflammation." Once only did he meet with a large abscess, such as we found in the first of our autopsies. Besides his own cases, Laennec says that he only knew of two other well-authenticated cases of abscess of the lung, notwithstanding the zeal with which pathological anatomy had been cultivated in France at the time he made that statement: one of the cases was communicated to the Academy of Medicine in 1823 by Dr. Honore, and the other was published by Dr. Andral.* In support of this weighty testimony, I would adduce the statement of Professor Chomel, who, during twenty-five years, only twice found, in the pulmonary parenchyma, purulent collections which did not seem to depend upon tearing by the pressure of the fingers at the moment of removal from the thoraxf-an occurrence which frequently takes place in a lung infiltrated with pus. A purely peripneumonic vomica is consequently an exceedingly rare affection in adults, and under such conditions as were present in the cases which have occurred in our wards. Bear clearly in your minds then these cases, as perhaps ere long you may finds others like them. Let me now, in a few words, sum up the history of our patients-a his- tory interesting from many points of view. It is specially interesting in relation to the diagnosis of pneumonia; that is to say, the real diagnosis of the disease, with which the clinic can alone make you acquainted, and which sometimes embarrasses the most experienced physicians-not that ordinary diagnosis, so simple and so easy, which may be learned theoreti- cally from text-books. The first of our patients was a young man of robust constitution, twenty- six years of age. You first saw him lying in bed 19, and then in bed 7 of St. Agnes's Ward. He had been ill four days when admitted to the hospital on the 24th March. His illness had commenced with a violent pain in the left shoulder, after exposure to a sudden transition from heat to cold, on leaving a ball. He, nevertheless, went to his work next morning; and although on the evening of that day, there was an increase of pain, and though with this, he also had fever, oppression of breathing, and cough, and although he had passed a sleepless night, he again returned to his usual employment on the 23d March : he ate little at his midday meal; and in the evening, he had difficulty in regaining his lodging. During the night, the pain in the shoulder became still more severe, and with it there was also pain in the chest below the left breast: this increase of pain was accompanied by severe rigors. On the 25th. as I have already stated, he entered the Hotel-Dieu; and I saw him next morning. He had intense fever; and his countenance indicated extreme anxiety. He was greatly excited: but the only complaint he made was of pain in the shoulder, which was increased by coughing and the exertion of breathing, which was embarrassed and difficult. Although the movements of the shoulder-joint were painful, the pain in that region was not increased by pressure: he made but moderate complaint of the stitch in his side. There was no expectoration accompanying the cough. However, the intensity of the * Andral: Clinique Medicale, t. ii, p. 313. f Chomel : Dictionnaire de Medecine. Paris: 1842. T. xxv, p. 151. PERIPNEUMONIC VOMIC2E. 653 fever, and the very anxious appearance of the patient, made me think of a deepseated pneumonia, inaccessible to our means of investigation ; while on the other hand, the local pain suggested the commencement of an attack of articular rheumatism, which might perhaps declare itself next day. Following the latter indication, I caused ten scarifying cupping-glasses to be applied to the seat of the pain. Since the evening, there had been diminution in the pain of the shoulder, but an increased severity of the stitch in the side, accompanied by extreme anxiety, by considerable em- barrassment in the movements of respiration and coughing. Next day, these symptoms were very decided : the fever was more intense, and the excitement was greater. On percussion, only slight dulness was detected in the region of the heart: no morbid phenomenon was revealed by auscul- tation. The pulmonary expansion was, it is true, interfered with, by the pain impeding the movements of the thorax. The sputa, which up to this time had been scanty and albuminous, now presented the yellow color of barley sugar: they had a viscid consistence and were expectorated with difficulty. In the evening, the sputa had additional characteristics: they were sanguinolent, apoplectic, of a bright red color, frothy, but still tena- cious. My diagnosis of pneumonia was confirmed, although the physical signs were absent, except some dulness in the region of the heart detected by percussion : this dulness was limited to an extent of about ten centime- tres from the nipple to the sternum, where a certain amount of arching was perceptible : pressure in this region occasioned acute pain. I came to the conclusion that there was pericarditis complicated with pneumonia. The autopsy, to the description of which I shall return, showed me my error in diagnosis: there was only extensive hypertrophy of the heart. On the 23d, I ordered twenty scarifying cupping-glasses to be applied to the region of the heart, and at the same time ordered a continuance of the precipitated sulphuret of antimony, which had been ordered on the previous evening, one gramme [15| grains] being made up in ten pills. The expectoration, always difficult, had again changed its character : the sputa had the color of the juice of prunes, was somewhat viscid, and ad- hered to the vessel. It was not till the 29th March, the fifth day of resi- dence in hospital, and the ninth from the beginning of the illness, that we began to hear crepitant rales; but, when under the ear, they sounded so distant, so difficult to appreciate, that even their existence might be dis- puted. The general symptoms continued, and, moreover, increased in severity. On the 30th March, the sputa had assumed a chocolate color, without having any fetor. On auscultating the chest, there was heard tubal blow- ing of very unequivocal character, although it seemed distant from the ear, and mixed with mucous rales of average coarseness. The resonance of the voice was broncho-aegophonic. The dulness in the infraspinous fossa was replaced, from the inferior angle of the scapula downwards, by exag- gerated resonance, which could be elicited by strong percussion. This exaggerated resonance was so great anteriorly, down as far as the mamma, even when the percussion stroke was moderate, that the sound seemed to be abdominal. I therefore said : this man has pneumonia, a central pneu- monia, which invading the anterior part of the lung has perforated the parenchyma, and determined an effusion of air and pus into the pleural cavity, establishing a communication between that cavity and the bron- chial tubes. In a word, I diagnosed a peripneumonic vomica and hydro- thorax. On the 31st March I observed that the vesicular murmur under the left clavicle had become weaker, and that towards the precordial region there 654 PULMONARY ABSCESSES AND was heard distant amphoric blowing: lower down the respiratory sound was absent. Behind, the vesicular murmur was so feeble as to be scarcely heard at all in the scapular region: from the inferior angle of that bone it gave place to very distant amphoric blowing: there was a somewhat obscure metallic resonance of the voice, and the sounds of the heart were heard posteriorly by conduction. On the 1st of April the expectoration, which in the evening had a choco- late color, beginning to mingle with greenish sputa, became copious: it con- sisted of a pretty thick fluid, in which floated sputa which were frothy, not viscid, and free from any trace of blood. By auscultation we could still hear amphoric blowing, which came and went alternately, to which there was added a sound similar to that caused by bubbles of air traversing a fluid in a state of ebullition. On the 3d April the severity of the general symptoms had so much in- creased, the state of matters had become so alarming, so desperate, that it was quite out of the question to think of making the patient change his position to examine the chest behind. Expectoration was scanty, and in the spittoon there were only four or five large, thick, greenish, purulent sputa. The pulse was 140, small, and intermittent. The skin, which was covered with a viscid sweat, presented a very characteristic cyanosed appear- ance. There was extreme anxiety, great oppression of the breathing, and an almost complete extinction of the voice. On the 4th April this young man was in a dying state. During the night and morning he had brought up a great quantity of thick, creamy, greenish- white, inodorous pus, which filled two spittoons. In the evening low de- lirium set in, and on the morning of the 5th April he expired. At the autopsy we found the lesions to which I have called your atten- tion: we likewise found, as I have already stated, that the pericardium was quite unaffected; but the heart, very bulky, occupying the space which I had marked out with the pleximeter, rested on the indurated lung, thus, no doubt, giving rise to the thoracic arching and precordial dulness which had led me to suppose that there was pericarditis. Our second patient was a man of thirty-three, and was also, like the former, of strong, vigorous constitution. For six months he had been com- plaining of frequent headache and great lassitude. On the 8th April, eight days before his admission to the Hotel-Dieu, he felt more fatigued-more foundered \jplus fourbit]-to use his own expression, than usual. He had been attacked with fever, unaccompanied by decided rigors, or stitch in the side. He said that at that time he had no oppression of the breathing, a statement however of no importance, as on admission he declared that he had no oppression, although I could see that it decidedly existed, respira- tion being short, quick, and anxious. He had a great deal of fever. Ou percussion the sound was natural on the right side of the chest; on the left side, anteriorly, below the clavicle, the sound was exaggerated, skodaic. Behind there was dulness from the top to the bottom of the chest. The vesicular murmur, normal on the right side, both before and behind, was likewise natural on the left side, where we detected the resonance; but, be- hind, it was replaced by very intense tubal blowing and bronchophony: its maximum intensity was in the infraspinous fossa. On the evening of the day upon which he came into hospital, he had only brought up one spit, which was saffron-colored, frothy, aerated, and non- adherent to the vessel in which he expectorated. On the morning of the 9th his spittoon was filled one-third with greenish diffluent sputa, some of which were brownish, reminding one of rusty sputa. I directed two palets [19 fd. ounces] of blood to be taken; and at the same time prescribed 50 PERIPNEUMONIC VOMICA. 655 centigrammes [nearly 8 grains] of precipitated sulphuret of antimony in five pills. In the evening of the same day the blood, which had flowed freely, presented a diffluent appearance: the non-retracted crassamentum was covered with a thin greenish-huffy coat. The pulse was compressible and soft, as in the morning. It was impossible to venture upon the farther abstraction of blood. On the 10th April the spittoon was still filled one-third with very diffluent aerated sputa, having the appearance of dirty gum, with a slight look of prune-juice. The pulse had the same frequency, and the same other char- acters, as on the preceding evening. There was extreme oppression of breathing, which increased during the evening. The patient fell into a drowsy state: his expectoration assumed a chocolate color: his pulse, which was very soft, beat 136 in the minute. He died on the 11th April, at four o'clock in the morning. On opening the body, there were found the lesions of suppurative pneu- monia, and perhaps what was an incipient vomica, as I stated to you. To these two cases of peripneumonic abscesses, I shall add a third, nar- rated by Dr. Graves in his Clinical Lectures-in the lecture on " Abscess of the Lung. " Early in the spring of 1841, Dr. Graves was asked by Dr. Brereton to see with him at Sandford a lad between fourteen and fifteen years of age, who, a fortnight previously, had suffered from the symptoms of pleuropneu- monia, with acute pain in the side and very violent cough. He had had the characteristic expectoration, as well as sputa of the color of prune-juice. The general symptoms, as well as the local inflammatory symptoms, were very severe; and did not yield to the treatment, which was both judicious and active. About ten days after Dr. Graves's first visit, matters were pro- ceeding from bad to worse, and at that time the pulse was nearly 140 : there was very great dyspnoea, excitement, jactitation, insomnia, and a cough ceaseless by day and by night. The case seemed desperate, and, hour by hour, death was looked for. Almost the whole of the right lung was in- volved in the pneumonia; and there was great dulness on that side. It is noteworthy, that in the first stage of the disease, crepitant rales were heard throughout the whole of both lungs. The distinguished clinical professor of Dublin was well aware that this was a case of pleural vomica; but nevertheless, he is careful to mention the important fact that at the beginning of the illness, the patient had crepitant rales throughout the whole of both lungs, which hardly left any room for doubting the existence of pneumonia. I wish here, however, to make a reservation. Graves says: " Crepitant rales were Aeard; " I should have preferred that he himself had heard them. When matters were in the gloomy state now described, the patient was one night affected with very great difficulty in breathing, anxiety, and pain in the side : he was supposed to be at the point of death. All at once, after a sudden effort, he brought up a large quantity of purulent matter; and immediately afterwards felt comparatively well. Next night, a similar struggle occurred, and was followed by a similar result. In the morning, when Dr. Graves saw the young man, he found him better in several re- spects ; but he still had extreme debility with a great deal of fever and dyspnoea. On examining the right side of the chest, Dr. Graves found that the anterior part, from the clavicle to the base, as far down as the diaphragm, yielded a sound very different from that which it had previ- ously rendered on percussion: it was then dull-now it was clear. This side of the thorax was evidently dilated ; and, by the stethoscope, metallic tinkling was heard whenever the patient coughed or spoke. This satisfied 656 PULMONARY ABSCESSES AND Dr. Graves that there was a very large cavity in the lung, communicating in one direction probably with the bronchial tubes, and in the other with the pleural cavity. He looked on the case as hopeless. Fifteen days from that date, or, possibly, a little later, the expectoration again became puru- lent, and this recurred: but each time, the quantity was less, and the state manifestly ameliorated. In six weeks from the occurrence of the first puru- lent expectoration, convalescence was far advanced ; and ultimately, the young man became strong and in perfect health. The two cases which we have observed together in the wards, the case of Graves (who reports others of the same kind), the cases observed by Laen- nec, by Honore, and by Professors Andral and Chomel, incontestably prove the possibility of a purely inflammatory peripneumonic vomica. But it is not enough, gentlemen, to detect a vomica at the opening of the dead body : we must endeavor to diagnose it in the living patient. Let us inquire, therefore, whether there are any other signs by which recognition of this diseased state can be made during life. The elements of this diagnosis are generally scanty. The signs indicated by Laennec, the coarse, bubbling, mucous rales, manifestly cavernous, audible in the situation of the abscess: marked pectoriloquy taking the place of the bronchophony which previously existed ; the respiration and the cough, previously bronchial, becoming cavernous; the blowing being in the ear, when the abscess is near the surface of the lung, and muffled, when a part of the wall of the abscess is thin and soft,-these signs have very rarely been ascertained to coexist. They are very far from being so easy to distinguish as Laennec alleges: the pectoriloquy, and particularly the blowing heard in the ear, belong equally to pleural and peripneumonic vomicae: this is the conviction which is left on the mind by reading the chapter in Graves's clinical lecture upon abscess of the lung. Graves re- ports three or four cases, occurring in the practice of himself and Stokes, of pleural abscesses, which opened into the bronchial tubes. On considering, however, what took place in the subject of our first case, on considering that the vomica was detected during the life of the patient, one is obliged to admit that some characteristic signs do exist. But in my opinion, there are some signs of greater importance than those pointed out by Laennec. There has been, let us suppose, an acute, a very acute attack of pneu- monia : then, at a later period, the individual expectorates a large quantity of puriform matter mingled with blood, and, in consequence of this admix- ture, presenting a chocolate color: sometimes, the expectoration is difflueut, at times resembling the sputa of pulmonary apoplexy, and at other times like the fluid of certain hepatic abscesses situated in the substance of muscles. It is a mixture of blood and pus. New stethoscopic phenomena become observable at the same time : in a limited portion of lung, there is amphoric respiration, a gurgling, bubbling sound ; and along with this there is some- times a metallic tinkling which passes into the cavity. • It was not from the expectoration alone that I formed my diagnosis in the first case. The sputa, at first hemorrhagic, became, however, of a choc- olate color, that is to say, mixed with pus and blood. On the sixth day from his admission to the hospital, which was the tenth day of his illness, symptoms of hydropneumothorax all at once showed themselves ; then also was observed profuse purulent expectoration ; and then, too, it was that I diagnosed the vomica. To arrive at such a conclusion, however, it is neces- sary to have a conjunction of all these signs,-a peculiar expectoration, amphoric blowing, and metallic tinkling. In the case of our second patient, in whom I thought a vomica was beginning to form, in whom the pulmonary abscess was still filled with the PERIPNEUMONIC VOMICA. 657 putrilaginous matter which you saw at the autopsy, we only discovered the existence of pneumonia in its third stage : and you can understand how dif- ficult the diagnosis was in other respects, the burrow not being as yet empty, and neither communicating with the bronchial passages, nor with the pleural cavity. Therefore, it is, that the quantity of the sputa, the sudden increase in their quantity, their special character, their becoming diffluent after having been viscid, are the circumstances which guide us to the diagnosis of an open vomica, whether the opening be simply into the bronchial tubes (as in our case and in Graves's case), or into the pleural cavity as well as into the bronchial passages. The time at which this communication is established is perhaps the capital element in the diagnosis. It is almost impossible for a peripneumonic vomica to remain long without opening. An abscess formed in the parenchyma of the lung will try, like every other purely inflammatory abscess, to open externally, and the pus will necessarily find an exit by the divided and ulcerated bronchial tubes, which correspond to the cavity of the abscess: if at the same time it opens into the pleural sac, the peripneumonic vomica does not with less rapidity find an outlet by the bronchial tubes. Indeed, there is not on record any case in which the for- mation of the opening has occurred later than the twentieth or twenty-fifth day. Abscesses which open on the fortieth, fiftieth, or sixtieth day, are abscesses of the great pleural cavity, or abscesses between the lobes of the lung. In fact, in numerous cases, we find between the lobes of the lung a collection of fluid sometimes serous, sometimes sero-purulent, which is im- prisoned between the lobes by false membranes closing in the interlobular fissure: these collections, to a certain extent independent of the pleural cavity, nevertheless belong to the pleura: like purulent collections in the pleural cavity, they may find an outward passage through the bronchial tubes by perforating the pulmonary parenchyma; and when this state of matters exists, the patient presents all the symptoms of pleural vomicae. But as there is necessarily an absence of the signs of effusion into the great cavity, as there is only a dulness which seems to depend upon the state of the lung, the conclusion arrived at will be that therp is a peripneumonic vomica. These supposed abscesses of the lung, however, are, I repeat, very long in opening-six weeks, two months, three months, or sometimes it may be, four months from the commencement of the pleuropneumonia. This original pleuropneumonia causes the mistake: it has been followed in all its phases, and that which has been ascertained to exist has appeared to be its sequel, and to be related to the pulmonary and not to the pleural lesion. You are, under such circumstances, the more inclined to believe that there is pulmonary vomica-the sounds of gurgling seeming to be limited to the lung, and not being accompanied by the usual signs of hydropneumothorax. That which takes place in interlobar pneumonia, occurs also in circum- scribed pleurisies of the great pleural cavity itself. From the numerous examples you have seen, you are aware that under certain circumstances adhesions take place between the pulmonary and costal pleura, that a pleurisy at the base of the lung terminates in resolution, while a pleurisy at the upper part of the lung does not enter upon resolution, but proceeds to suppuration. There then supervenes a lesion difficult of recognition. Suppose that a pleuropneumonia has previously existed: the pulmonary inflammation was manifested by bloody mucous expectoration, and after- wards the sputa assumed a rusty color, and looked like apricot marmalade : by the stethoscope, pathognomonic crepitant rales were heard: the pleurisy itself had been characterized by the violent stitch in the side, differing from that sensation of weight and pang which the old authors connected more vol. I.-42 658 PULMONARY ABSCESSES AND particularly with the existence of peripneumonia. Adhesions were formed between the inflamed lung and the costal pleura. The remaining pleuritic effusion between the adhesions first became seropurulent, and then entirely purulent. There can still be perceived in the situation corresponding to the dulness and the blowing, a very considerable bellows-sound notwith- standing the great quantity of effusion, for, as you are aware, a considerable amount of blowing is not inconsistent with great effusion. This then was a case of circumscribed pleurisy; and in that situation, the compressed lung, becoming squeezed on itself, was at last completely flattened by the effusion. It then becomes very difficult to follow the evolution, which leads to the belief that pulmonary induration exists alone, in consequence of the steth- oscopic signs being bronchial blowing, vocal resonance, and sometimes even coarse gurgling rales, phenomena which occur within the as yet unflattened bronchial passages, and are transmitted across the condensed pulmonary parenchyma and the effused fluid within the pleural cyst. Under such circumstances, the diagnosis is-pneumonia, which has become chronic. However, in two or three months from the beginning of the attack, the pa- tient brings up a large quantity of pus by the mouth-in the literal mean- ing of the term, he has a vomica-he vomits: you then hear within the chest, gurgling and the bursting of large bubbles, as well as metallic tink- ling; and you come to the conclusion that in the indurated portion of lung, a cavity has been formed, that cavity being constituted by the pleura. In this case, the sole element of differential diagnosis was the time of the opening of the abscess-the time of appearance of the vomica; as I have just been saying, of all the signs which have been mentioned as diagnostic of pulmonary abscess, tiihe of appearance is certainly the most important. By paying special attention to this sign, the mistaking pleural for pul- monary, and pulmonary for pleural abscesses may be avoided, particularly if the patient has been under observation from the beginning of his attack. On the other hand, when the patient is not seen till an advanced period of his malady, such mistakes, though much more readily committed, may still be avoided. Indeed, generally speaking, pleural effusion is easily recog- nized : complete dulness, and distension of the chest, never-absolutely never-accompany pneumonia; and there is nearly always absence of tho- racic vibration: these are phenomena sufficiently characteristic. It is true that in some exceptional cases, thoracic vibration is absent in pneumonia; and it is also true, that thoracic vibration may exist in some cases of pleu- risy, as, for example, in pleurisy accompanied by bronchophony. But when, in addition to the phenomena now pointed out, we meet with others, such as the crushing up of the mediastinum, and the pushing over of the heart to the unaffected side, the pressing down of the liver or spleen, one can have no doubt as to the existence of extensive pleural effusion, nor will there be any chance of mistaking it for pneumonia. But if, in these cases, the patient has suddenly vomited a large quantity of pus, you may, with- out any farther examination of the chest, without using stethoscope or pleximeter, affirm that the pus comes from the pleura. Auscultation will generally confirm this diagnosis, by enabling you to recognize the signs of hydropneumothorax. This is a point upon which I have insisted, when discussing the history of pleurisy and pneumothorax. At present, I shall only recall to your recollection the fact that these large pleural purulent collections may open into the bronchial passages without necessarily causing any great harm to the individual. Three years ago, Dr. Bordes called me to see with him in consultation PERIPN EUMONIC VOM1CJE. 659 a fruiterer of the Rue des Gravilliers: our appointment was, to meet at this man's house at half-past ten in the morning. Dr. Bordes had detected considerable effusion in the chest, dating back two months and more: he begged me to bring with me the instruments necessary for performing para- centesis of the chest; and consequently I went prepared to operate. On my arrival, the patient showed me a salad dish containing five litres of pus, which he had vomited during the night. During the day, he contin- ued to bring up pus in large quantities, and within less than a week, he brought up eleven litres by exact measure. He continued for three weeks or a month to vomit pus, to use his own expression. At present, he is in excellent health. Large pleural vomicae, then, may, like pulmonary vomicae, open into the bronchial passages; but, irrespective of the signs which I have given you, the very quantity of the pus brought up will not allow the practitioner for one moment to have any doubt as to the nature of the case. No abscess of the lung can contain a litre of pus : that I hold to be impossible, but a pleural abscess may contain two, three, or four litres; moreover, as the pus is renewed day by day, the quantity brought up by an individual may be much greater. For example, Legroux mentions the case of an individual, who-during a period, it is true, of considerable duration-brought up from 42 to 43 litres, actually measured ; and at a meeting of the Medical Society of the Parisian Hospitals, in 1854, I read an account of the case of one of my patients, a girl six years old, operated on for empyema, who, within a period of rather more than six months, brought up pus estimated at 200 grammes a day, making the enormous total weight of 40 kilogrammes. The capital difference between the quantity of pus expectorated in cases of pleural and pulmonary vomicae simplifies their differential diagnosis. The difference in the quantity of pus expectorated, and the different period at which the vomica opens, constitute the essential elements of the diag- nosis. In children, however, the last-mentioned diagnostic element may be wanting. In children, purulent collections in the pleura may open very quickly into the bronchial tubes. Suppose a case of pleurisy in which the diag- nosis has been made with exactitude at the beginning of the attack. Effusion has been detected, and its increase observed : symptoms soon show themselves indicating that the effusion has become purulent: at last, about the fifteenth, twentieth, or eighteenth day of the attack, the patient brings up pus in large quantities. The existence of a pleural vomica is in such a case established beyond the possibility of mistake. In the adult, cases of this description are of exceptional occurrence ; but they are sometimes met with in persons of suppurative diathesis. In puerperal women, for example, you may have rapid formation of pleural abscesses; and you may also have them opening into the bronchial tubes very rapidly, much more rapidly than in ordinary cases. Under such circumstances, there might be great difficulty in establishing the diagnosis, owing to the element of doubt introduced by the expectoration of pus ; but if we have seen the cases when the first symptoms set in, if we have then perceived the presence of a sup- purative pleurisy, the connection of the suppurative phenomena with the puerperal condition and general symptoms of the patient, will suggest them- selves to your minds ; and when the vomica bursts externally,, you will realize the necessity of being guarded in your prognosis. To complete my remarks on pulmonary abscesses, let me add a few words on their pathological anatomy and mode of termination. In respect of their pathological anatomy, I would call your attention to the charac- 660 TREATMENT OF PNEUMONIA. ters which distinguish purulent collections originating in acute simple inflammation from the vomicae met with in phthisical subjects. On this point, I cannot do better than quote the exact words of Laennec. He says: " Although in some cases, the color and aspect of tuberculous matter are very similar to those of pus, tuberculous matter generally differs from pus by containing an admixture of fragments of softened friable tubercle. Moreover, the circumscribed character of the cavities formed by the softening of tubercle, the firm consistence of their walls, the soft false membrane by which they are always lined, and the semi-cartilaginous membrane which sometimes succeeds to this false membrane, are sufficient to characterize a lesion very different from the above-described abscesses." I would add, gentlemen, to this description of Laennec, that one never meets with a tuberculous vomica, without finding at the same time numerous tubercular masses at different stages in one or both lungs. Regarding the prognosis, I cannot speak from my own experience alone; because, as I have already told you, I never had a case of pulmonary abscess till I met with the two which have given occasion to the present lecture. Judging from these cases, and from what has been written on the subject, I believe that pneumonia terminating in pulmonary abscess is generally mortal. No doubt, Laennec, Graves, and others, show the pos- sibility of recovery by the abscesses opening into the bronchial tubes, and cicatrization of the cavities taking place; but without denying the possi- bility of cure in this way, I agree in opinion with those physicians who re- gard such cases as altogether exceptional. In the treatment of cases of pulmonary abscess, as you can understand, gentlemen, there is nothing special to be done. Up to the time that the existence of the pulmonary abscess is ascertained, the treatment in no re- spect differs from that of ordinary pneumonia: and when we ascertain that the abscess is actually formed, intervention can avail nothing, as the abscess is situated beyond the reach of our remedial resources. LECTURE XXXVI. TREATMENT OF PNEUMONIA. Simple Pneumonia without any Complication.-Expectant Medicine.-Local and General Bleeding.-Blisters.-Antimonial Preparations, particu- larly the Precipitated Sulphuret \_Kermes~\ in large doses according to Basori's Method. Gentlemen: I am certain that in all the different hospitals which you frequent, there are no wards in which the local and general abstraction of blood is resorted to so cautiously [aw sobrement] as in mine. This arises from the fact that as yet the necessity, the utility even, of bleeding does not appear to me to have been made out so clearly as is believed by the majority of physicians, to whom the denial of the efficacy of abstracting blood in pneumonia would seem the denial of a demonstration. Even in pneumonia, a disease which, according to received ideas, demands bleeding more than any other, you seldom hear me order it. If I some- times have recourse to it, it is because it seems to be indicated by certain TREATMENT OF PNEUMONIA. 661 complications of the case, rather than with any view to combat the ordinary inflammatory element of pneumonia: the cases in which I resort to it are too fewT in number to weaken in any degree the general applicability of the rule by which I have been guided in this matter for many years. Gentlemen, this practice differs so essentially from that which I may say is almost universally followed-from that which is followed by the majority of your teachers, my colleagues as hospital physicians, and by the classical authors whose works are in your hands-from that which is accepted as orthodox by non-medical public opinion, which does not recognize the pos- sibility of inflammation of the lungs being cured without the abstraction of blood-that I am bound to explain myself to you fully on this subject, and to expound my views on the treatment of pneumonia. But before grappling with the merits of this interesting question, it is essential clearly to define the terras employed in the discussion. Pneumonia is not uniform in its character: the forms which it assumes, its greater or less intensity and extent-the influence of the prevailing medical constitution-the personal specialties of the patients in respect of age, sex, temperament, and previous health-the diseases which may com- plicate pulmonary inflammation, and the unfavorable conditions which may supervene during its course-all demand particular inquiry on the part of the physician. He must take special account of all of them, for they gueatly modify the disease, and are also the source of much diversity in the therapeutic indications. For the present, I shall delay consideration of that particular form of pneumonia, which I very willingly call catarrhal pneumonia, and which is observed in the early years of infancy and childhood, which is in the adult one of the most formidable epiphenomena of serious fevers; and also, par- ticularly, of measles and hooping-cough, as, on former occasions, I have pointed out to you. I shall also, for the present, say nothing of pneumonia complicated with symptoms giving it a special stamp: it will be sufficient for me to name bilious pneumonia, so remarkably described by Stoll, but which is seldom met with in the present day, a circumstance probably explained by the existing medical constitutions differing from those under which Stoll ob- served ; ataxic and adynamic pneumonia, which take rheir names from the predominance of nervous symptoms; arthritic and rheumatic pneumonia, unquestionably species of pneumonia, though their existence has been denied by some. The kind of pneumonia of which I wish to speak to you to-day is peri- pneAimonia vera-simple legitimate pneumonia-that form of the disease which most frequently presents itself to our notice, and generally supervenes from an accidental cause, generally from a chill. I shall now rapidly sketch its principal features. The period of incuba- tion is either short, or has had no existence. The malady is generally ushered in by a shivering fit; but this phenomenon is sometimes absent. The local phenomena generally open the scene. There is a stitch in a part of the side of variable extent: it is complained of by the majority of patients as existing at the base of the lung, more particularly under the nipple: it is generally increased by the inspiratory movements and by coughing; and is intensified by pressure. The respiratory movements become accelerated; and there is oppression of the breathing-much more, however, in appear- ance than in reality. The cough, at first dry and distressing, is almost never absent. The local phenomena are accompanied by intense fever; the skin is hot, having sometimes a burning dryness, but being more usually covered with a greater or less amount of perspiration. The patient com- 662 TREATMENT OF PNEUMONIA. plains of a feeling of discomfort, general bruising, and headache: the coun- tenance appears flushed and excited: the tongue is covered with a white saburral coating, and is sometimes yellowish towards the base: there is in- tense thirst, and no appetite for food. Bilious vomiting is often the first symptom : diarrhoea is very common at the beginning of the illness; gener- ally, numerous herpetic bullse appear on the lips and around the nostrils. During the first twenty-four hours, the cough is generally dry, as I have just stated, or at least the expectoration which accompanies it has as yet nothing characteristic of the malady; but on the following day, it begins to assume more and more that appearance which is destined to become spe- cific. Peripneumonia sputa are viscous, glutinous, semi-transparent, and minutely aerated : although, as yet, they have not much of the rusty char- acter, nor are they, as a rule, very sanguinolent, some of them at least pre- sent occasional striae, or a small compact nucleus, the color of which passes from amber-yellow to the tint of barley-sugar. This coloration, due to the admixture of blood with the mucous secretion, becomes more and more marked, presenting different shades, particularly that of apricot marmalade, of saffron, and of iron rust. At the same time that the sputa undergo these changes, they become more abundant, coalesce into one mass in the spit- toon, and form a sheet, semi-transparent like the cornea. The sputa strongly adhere to the bottom of the vessel. They are of themselves sufficient to enable us to recognize the nature of the disease; but other physical signs, the existence of which we are able to discover by auscultation and percus- sion, are pathognomonic of inflammation of the pulmonary parenchyma. These signs do not show themselves during the first twenty-four hours: at least, percussion furnishes no positive element of diagnosis, thoracic reso- nance not being sensibly modified, and auscultation affording little more than negative results in respect of changes in the respiratory sounds. But on the second day, a dulness more or less appreciable reveals itself in the parts originally affected; and there are also heard in that situation anoma- lous sounds which become more and more decided. The earliest of these sounds is a fine and very equal crepitant rale, which is heard during inspiration: the shocks imparted by the cough, so far from causing it to disappear, make it reach the ear of the auscultator in blasts. This crepitation tells us that there is engorgement of the lung; and I need not here discuss the theories which have been advanced to explain the pro- duction of this crepitation.* This rale is accompanied by, and soon after- wards replaced by bronchial respiration, which has also received the name of bronchial blowing. This blowing sound presents different varieties: some- times it is distant from the ear; and at other times, on the contrary, it is harsh and noisy; sometimes it is large and diffuse, and at other times limited and resounding, constituting tubal blowing. It generally begins by replac- ing the sound of expiration only, but it afterwards invades that of inspira- tion, and then accompanies both expiration and inspiration. The voice, * Without desiring to diminish in the smallest degree the glory of Laennec, to whom belongs the whole of the honor of having both discovered auscultation, and of having at one stroke as it were brought it to a very high pitch of perfection, it will, I think, be interesting to quote in this place the following passage from Van Swieten, according to whom it would appear, not only that the ancients had an idea of the existence of the crepitant rale, but likewise gave a theoretical explanation of its cause. Van Swieten says : " Plerumque tunc simul adest ingratus inpectore strepitus, qui fit vel ab acri muco hie collecto, irretitio: vel a vesiculis pulmonum siccis, hineque or epit anti.bus instar corii rarefacti, dum inspirando extenduntur."-G. Van Swieten, Comment, in Herm. Boerhaavii Aphor., § 826, Peripneumonia Vera, t. ii, p. 659. TREATMENT OF PNEUMONIA. 663 which has hitherto been only slightly resonant, now loudly resounds in the bronchi, and is transmitted to the ear by the hepatized pulmonary tissue, which, being more dense than the remainder of the lung, becomes an excel- lent conductor of sound. This bronchophony is never more marked than when it occupies the root or summit of the lung, where the bronchial tubes are larger than elsewhere. Crepitant rales are also often heard within the same space in which the blowing sound and vocal resonance are audible. These characteristic physical signs of the disease which we are now study- ing sometimes escape detection, from the inflammation being confined to a central situation in the lung, or to a sufficiently careful examination not having been made. You may be able to hear the morbid sounds only in the axilla. The general symptoms continue along with the local phenomena, and they never show themselves in a more decided manner than from the fifth to the eighth day. The fever is more intense at that period. The flushing of the face is at its height, and is greater over the cheek bones. The red- ness in this situation was looked on by our predecessors as one of the char- acteristic symptoms of pneumonia. Physicians, encouraged by the alleged success of the Hahnemann sect in treating pneumonia, and following also other examples, have submitted their pneumonic patients to the expectant system. This method was adopted long ago by Magendie; and there are doubtless some among you who have heard of the recently published works of MM. Dietl of Vienna, Niemeyer of Griefswald, Schmidt, &c., and of the cases reported by Dr. Laboulbene: many must have read the posthumous treatise of Legendre, intituled, " De 1'Expectation dans la Pneumonie Franche."* Well, then, gentlemen, these experiments have made us acquainted with the natural course run by purely inflammatory pneumonia in a great number of cases. Generally speaking there is a tendency to spontaneous recovery, which usually occurs between the ninth and eleventh days. According to Dr. Bourgeois of Etampes,f who, for twenty-five years, has abstained from all active therapeutic treatment in pneumonia (and has pub- lished a short paper on the subject), there is, at the eighth day, a marked tendency to diminution in all the symptoms in the cases which do well. At that period the sputa are less colored and less viscid: respiration is a little less embarrassed: there is no longer pain in the side: there is a dim- inution in the thickness of the saburral coating of the tongue: there is a return of sleep, which, during the previous days, had been absent or had been replaced by a state of constant drowsiness: towards the close of the day the drowsiness ceases, and the patient begins to feel the want of resto- rative measures. On the ninth day there is almost always improvement: though there is more cough, it is looser: the sputa, albuminous rather than gelatinous, are nearly always colorless: the stitch in the side has quite ceased, unless it be that it returns during severe coughing fits, or on taking a deep breath: the tongue has become clean: there is a decided appetite for food: the urine, which was of a scalding character and scanty, during the acute stage of the pneumonia, becomes abundant, and nearly normal in character, having no deposit, and being devoid of turbidity, appearances which rarely show them- selves except during convalescence: in a word, the symptoms of the disease disappear, while its physical signs remain in their plenitude. * Legendre : Archives Generales de Medecine, for September, 1859. f Bourgeois (d'Etampes) : Union for 3d January, 1860. 664 TREATMENT OF PNEUMONIA. On the tenth day, the patient enters upon complete convalescence. At the end of the second week, should nothing occur to impede the progress of recovery, the patient is in a state to resume his ordinary occupations, provided they are not of a fatiguing nature. Nevertheless, upon ausculta- tion at this period, we still find the dulness, and also the crepitant rale which had replaced the tubal blowing, but it is the crepitant rale or, to speak more correctly, the subcrepitant moist "rale de retour," as it is called, indicative of the return of the air into the pulmonary vesicles, whence it had been expelled by hepatization. Several weeks will often be required for the complete disappearance of the signs of engorgement of the lung. In simple pneumonia the temperature rises rapidly after the shivering fit which occurred at the beginning of the attack: it often reaches, and sometimes goes above 39° during the early days of the disease. It then continues at that point, with however slight irregular oscillations. The case is serious when the temperature rises to or ascends above 40°. The fever generally abates on the 5th, 7th, or Qth day: this abatement takes place abruptly, and with rapidity: in twelve hours, or in thirty-six hours at the most, the temperature falls three degrees or more. As soon as the normal temperature is attained, resolution begins, and the patient may be looked upon as convalescent. At defervescence, it occasionally happens that the temperature falls for a very short time below the natural standard : in the cases in which this occurs, there is a temporary collapse. These data, derived from numerous researches of Wunderlich, you have had an opportunity of verifying in a patient who occupied bed 20 of St. Agnes's Ward. This man, aged 27, addicted to drinking and affected with alcoholic tremors, had extensive pneumonia at the upper part of the right lung. From the first days of his attack, the urine was found to contain a considerable quantity of albumen: he was delirious on the night of the sixth day of the disease, and during the seventh and eighth days the de- lirium continued. On the ninth day, however, a complete convalescence set in ; and by the eleventh day, there was no longer any albumen in the urine. Here is what occurred in respect of temperature: On the fourth day, the day on which the patient was admitted to the hospital, his tem- perature was 39° : on the morning of the fifth day, it had risen to 40.2°, and in the evening of that day it fell to 39.6°, under the influence of anti- phlogistic treatment: on the sixth day, during the whole day, morning and evening, it kept at 40.4°: on the evening of the eighth day, it fell to 39.8°, then on the morning of the tenth day, it fell to thirty-six degrees and six-tenths-which is below the normal standard, to rise again to 37° and 37.2°, where it definitively remained. I am unwilling to quit this interesting subject of temperature, without pointing out to you an important clinical peculiarity. At the beginning of an inflammatory affection of the chest, when there is stitch in the side, it is occasionally very difficult by unaided physical signs and the reaction to ascertain whether the inflammation is pneumonia or pleurisy: well, if from the first days of the attack, the temperature rises rapidly, reaching 39°, or, a fortiori, if it rise to a higher figure, pleurisy may be excluded, and pneumonia diagnosed: and likewise, the continuance of a relatively low temperature makes it probable that there is pleurisy, or, at all events, it excludes the idea of the existence of simple pneumonia. Are we obliged to conclude, that the treatment of pneumonia ought to be expectant, because recovery takes place spontaneously in a certain num- ber of cases ? I think not: and, moreover, when I find myself confronted with this disease, I cannot remain an inactive spectator. Whenever I am TREATMENT OF PNEUMONIA. 665 called in to a patient suffering from pure and absolutely uncomplicated pneumonia, I lose no time in intervening by antiphlogistic treatment. As I stated at the beginning of this lecture, I very rarely have recourse to the abstraction of blood, local or general. When there are symptoms of great general plethora, threatening to complicate the progress of the disease, I sometimes, though very rarely, cause a vein to be opened. After a single bleeding, however, of from four hundred to five hundred grammes, I seldom require to repeat the proceeding. To remove or moderate the stitch in the side, when the pain is excessive, I prescribe cupping-glasses to be applied to the seat of pain, abstracting or not abstracting blood as the case may be; or I inject some drops of a solution of atropine into the subcutaneous cellular tissue: but that is the limit within which I bleed in pneumonia. Bleeding, once extolled by physicians of the highest repute, employed for- merly in one form or another by almost all practitioners, is energetically objected to in the present day. Some clinical physicians not only deny its efficacy, but even regard it as generally injurious. The only cases in which they do not regard it as objectionable are those in which the inflammatory symptoms are accompanied by excessive reaction, such as intense headache, somnolence, and great dyspnoea. In such circumstances, even, though they sanction bleeding as a means of affording temporary relief, they insist on the necessity of drawing blood in moderation. Though in these cases, they admit that bleeding may prove palliative, they deny that it is ever a means of cure, far less do they admit that it ever has the power which has been assigned to it of cutting short the disease. And again, the physicians to whom I refer, looking to the statistics which have been drawn up to elu- cidate this question, have come to the conclusion that there has been a greater mortality in pneumonia among those who have been bled, than among those who have not been bled: and consequently, they say that bleeding has been the cause of the numerous deaths from pneumonia, not- withstanding the immediate tetnporary benefit which it affords. You have heard Dr. Beau,* in his clinical lectures, develop these ideas regarding the unfavorable effects which bleeding produces upon pneumonic patients. In citing to you cases from his own practice, in supporting his views by other cases quoted from the works of numerous French and foreign physicians, my honorable colleague of the Hopital de la Charite has en- deavored to explain them to you by entering into physiologico-pathological considerations. Although I also call in question the advantages of the abstraction of blood, the usefulness of which, particularly in the treatment of pneumonia, seems to me to have been vaunted beyond measure, I cannot agree with those who are the detractors of bleeding. Although I do not admit its utility in the majority of cases, allowance being made for the peculiar medical constitutions through which we have passed in recent years, yet, at the same time, I deny that it brings in its train the disastrous consequences ascribed to it, provided it be practiced with due moderation. If, as a general rule, I abstain from prescribing bleeding, it is not because I believe it to be the cause of the frequent deaths which have been attributed to it, but because my experience has taught me that it seldom shortens the duration of the disease, and frequently retards complete return to health, by weakening the patients, and prolonging the period of their convales- cence. Antimonials have not these drawbacks. Their antiphlogistic properties are as unquestionable as those of bleeding: the only difference is that they * Beau : Gazette des Hopitaux, for the 6th and 8th September, 1859. 666 TREATMENT OF PNEUMONIA. act in a different manner. While sanguineous evacuations suppress in- flammatory action by removing the materials which constitute its aliment, while they exhaust the disease by exhausting the patient, antimonial preparations act in a wholly different manner, and never bring along with them the extreme prostration which often accompanies the convalescence from pneumonia treated by repeated bleedings. This action of antimonials has been explained in many different ways. Rasori explained it by saying that these medicines exhausted the diathesis of the stimulus; but he did not define very well the meaning which he attached to that expression. According to Dance and Chomel, antimony does not possess any specific property. When there is a complete tolerance for it, they say that it is inert; and when it acts as an emetic or purgative, they hold that its action differs in no respect from that of any other evacuant. This opinion comes very near to that of Broussais, the eminent professor of the Val-de-Grace, who says that antimonials ought to be regarded as revulsives even more powerful than the blisters and the sinapisms, which are applied to the skin, inasmuch as they act upon a larger surface, and moreover often excite profuse discharge from the gastro-intestinal mucous membrane. Gentlemen, this is not the place to repeat a discussion which you will find given very fully in the article on antimony in my treatise on therapeu- tics. I nevertheless ask you to allow me to add what is there said on this head. As a general rule, I attach very little importance to explanations of the therapeutic action of medicines. In therapeutics, I only see two things-the administration of the medicine, and the result of that adminis- tration. As for the intermediate phenomena, they escape our observation, and perhaps will always continue to do so. Notwithstanding, I have hazarded my theory as to the mode in which antimonial preparations act; holding it, however, as very cheap, and being quite willing to abandon it for any other which may appear to me to be more in conformity with facts. I asked myself whether we might not grant that antimony exercised a special toxic action on the heart and respiratory organs, either directly or through the medium of the nervous centres, just as many medicinal substances have unquestionably a special action on certain organs. The existence of this specific action of antimony appeared to me to be demon- strated by its physiological effects as manifested by the pulse becoming slower and weaker, and by the breathing becoming slower. This fact being established, the therapeutic effects of antimonials in pneumonia may be ascribed to a diminution in the quantity of blood sent to the inflamed lungs, which, by having a less degree of activity, are in a state analogous to that in which the surgeon places a fractured limb-that is to say, in a state of relative if not in a state of absolute repose. Experiments on animals confirmed the views which I had formed as to the toxic action of antimonials upon the heart and organs of respiration. I had long previously enunciated the opinion I have now stated, when-in 1856-the experiments of Ackerman, and afterwards those of Pecholier, demonstrated its correctness. If, as has been done quite recently in con- firmatory vivisections, by my learned colleague, Professor See-if a solution of tartar emetic be injected into the veins of rabbits or of guinea-pigs, there are soon observed a decided lowering of the pulse, diminished ar- terial pressure, and frequently, likewise, irregularity in the pulsations. Along with this condition of the pulse there is a great depression of the vital powers. The lowering of the pulse and the diminution of arterial pressure are due to diminished frequency and diminished energy in the con- tractions of the heart; and this may be attributed to a direct, and to a TREATMENT OF PNEUMONIA. 667 certain extent paralyzing action of the tartar emetic upon the cardiac ganglia, which are the automotor ganglia of the organ. Whatever may be the explanation of their action, the utility of anti- monials in the treatment of pneumonia is now generally admitted. Violently and unfairly attacked by many, and inordinately extolled by others, the tartar emetic treatment has at last taken its place in the domain of thera- peutics. But if even persons who were the most incredulous have become convinced of the efficacy in pneumonia of tartar emetic in large doses, it is not so with some other preparations of antimony. The kermes, which you see me prefer to tartar emetic (for reasons which I am about to state), and the white oxide of antimony, which some believe to be inert, have not as yet acquired the same rights of citizenship. Nevertheless, there is evidence to show that, in the treatment of peri- pneumonia, the kermes is in no degree inferior to tartar emetic. It has, moreover, this advantage over tartar emetic, that it is much less irritating, and much more rarely produces the inflammatory affections of the throat and gastro-intestinal canal which prevent the continuance of the tartar emetic for a period sufficiently long to bring about resolution of the pul- monary inflammation* and particulary to prevent its recurrence. In respect of the white oxide of antimony, numerous cases have demon- strated to me its beneficial influence, particularly in the treatment of the pneumonia of children. There is, however, a necessity for giving it in large doses; and the actual good results may unquestionably be obtained by smaller doses of the kermes. Some persons have seemed surprised-their surprise, however, being more seeming than real-that I have appeared to abandon the use of cer- tain antimonial preparations which I lauded at a previous period of my professional career: narrow-minded and ill-natured individuals have made this circumstance the ground of bitter and insulting criticism. They might have spared me, had they remembered a great law of therapeutics, to the effect, that the medical constitution has an immense influence on the action of remedies. This grave question approaches too near the domain of clinical medicine not to be here discussed, just as in former times I discussed it before my classes at the Faculte de Medecine, and as Dr. Pidoux and I have discussed it in our Traite de Therapeutique. Medicinal substances, when administered to human beings, may be cor- rectly regarded as morbific agents similar to those which commonly beset us. Have the ordinary morbific agents always the same mode of action? To experience we must refer this question for a reply. A man, during a particular epidemic constitution, is exposed to the in- clemency of the atmosphere; he takes pneumonia, and, at a later period, articular rheumatism, pleurisy, or colitis. Here, therefore, there is the same cause determining an inflammation to different organs. This happens so frequently, that it is impossible for any one to deny that it is a common occurrence. During the cholera epidemic of 1832, causes apparently the least calculated to disturb the digestive functions produced diarrhoea, and sometimes a sudden invasion of cholera. Two years later, during the in- fluenza epidemic, the same cause which had before produced cholera gave rise to a special form of catarrh. No change had taken place in the cause; it was identically the same. Why, then, did it not produce the same effects ? In considering the way in which a cause acts, two things of equal impor- tance have to be borne in mind : first, there is the nature of the cause, which is always the same : and second, there is the support of the cause, that 668 TREATMENT OF PNEUMONIA. is to say, the economy within which the cause operates, which is subject to infinite variety, and reacts in virtue of idiosyncrasy, and also in virtue of an accidental tendency which exercises an immense influence. It is this accidental tendency [disposition accidentelle'] which, when distributed at the same time to a great number of persons in the same district is called the epidemic constitution: it bears the same relation to the general population that idiosyncrasy, or special constitution, bears to the individual. When, therefore, the whole, or nearly the whole of a population have one common accidental constitution, called medical or epidemic constitution, the same cause which but for this constitution would have produced certain known effects, will produce very different effects, because the support of the cause-the economy-has a different bias, in virtue of which its reaction is different. The medicine administered to the sick man not only finds him suffering from the particular ailment for which it is prescribed, but also, finds him under the influence of the common or epidemic constitution, which neces- sarily modifies the effects of the ailment. Suppose, for example, that a choleraic constitution prevails in a district. If mercurial frictions are em- ployed within that district, in puerperal fever, or articular rheumatism, exceedingly serious gastro-intestinal symptoms may supervene ; and the mer- cury, diverted from its normal action, irritates the intestine before manifest- ing its ordinary effects. The aptitude of the illustration now given is palpably evident: but the influence of the medical constitution is not less constant in a host of other circumstances in which the manifestations are less clear. Testimony to that effect can easily be collected from the writings of all intelligent medi- cal observers of the times anterior to our own. In the present day, a physician makes himself the champion of a thera- peutic idea, or rather of an experimental idea, which is not the same thing. He goes on for many years submitting all his patients, irrespective of age, sex, temperament, and medical constitution, to identically the same treat- ment : and month by month, and year by year, gravely registering the numbers of the deaths and recoveries, he finally deduces from these statis- tics therapeutic laws which he looks upon as irrefragable. It matters little to him that one year he had a frightful mortality to deplore, and that in another he had to congratulate himself upon a great number of recoveries. To him it is simply a question of figures : he adds up, and calls the result- a law! If you ask him how it is that fifteen years ago, he lost one out of three patients, while now he only loses one out of ten, he is scarcely at all dis- concerted ; and with assurance concludes that the disease was much more serious then than now. This conclusion would have been legitimate had he left his patients to the unaided powers of nature; but he does not take into account his treatment, and he does not perceive that possibly the year in which he lost the greatest number of patients was that in which the mortality might have been least, had any other treatment been adopted. On reading with attention what has been so beautifully written by Syden- ham and Stoll upon the modifications necessitated in therapeutics by the epidemic constitutions which have been observed with so much care, there is produced, on the one hand, the conviction that the physicians who go on continually pursuing the same treatment, notwithstanding a change in the epidemic constitution, are men of narrow views; and, on the other hand, that there is a very great influence exerted by the epidemic constitution upon the action of the same medicines in diseases of which the local mani- festations are the same. TREATMENT OF PNEUMONIA. 669 You can now understand, gentlemen, why in saying, at the beginning of this lecture, that the necessity, the utility even of bleeding in pneumonia, did not appear to me to have been clearly demonstrated, I took care to add, in respect of the present time. In fact, for years past, we have been travers- ing medical constitutions which do not necessitate recourse to that treatment, just as in the past, there have been medical constitutions which required it, and as there may be others in the future also demanding it. So also, when Stoll, and still more when Riviere lauded the tartar emetic treatment, that treatment responded to the indications of a then dominant medical constitution. For a long time past, that constitution has not shown itself, and the bilious symptoms, these which specially demand evacuant treatment, have not been recently observed. Let me now resume consideration of the subject of antimonials adminis- tered in large doses. To enable you to estimate correctly the immense difference which has been found to exist between their action as studied at different periods, it will be sufficient to glance at their immediate effects: and this will enable you to judge as to what may be their secondary influence. You will readily admit, that if it be possible to form an erroneous opinion regarding the secondary results of a particular treatment, there is never any room for mistake as to the immediate action. Though during a particular period, both in hospital and private practice, I could not prescribe for adults more than a gramme a day of the white oxide of antimony without exciting vom- iting and diarrhoea-though during the same period I could not give in a day more than from 30 to 50 centigrammes of kermes, and that too, only when tolerance was secured-by administering along with it, a considerable dose of opium-though in fact, during the period I refer to, I was obliged to discontinue the use of the tartar emetic from the patients being unable to bear it, and from its always leading to serious symptoms-at another time, I have fearlessly given to an adult as his first dose 16 grammes of the white oxide of antimony in twenty-four hours, without the patient experi- encing even the slightest nausea. I have at another time carried the dose of the kermes up to two or three grammes, without its being necessary to combine it with opium : and have without hesitation prescribed a gramme of tartar emetic, this large dose hardly inducing vomiting more than once or twice. The immediate effects being so different, are we not justified in asking, whether the secondary effects do not vary as much ? The fact ought to be recognized, that there is no ground for giving an absolute preference to any one of these preparations over the others; and it ought also to be under- stood that the dose in which they ought to be prescribed is subordinate to the influence of the prevailing medical constitution. You perceive from what I have said, that the self-contradiction with which I am taunted in respect of the therapeutic properties of these prepa- rations of antimony is more apparent than real. Finally, that which seems to me at present to succeed best in the treatment of pneumonia-simple and perfectly uncomplicated pneumonia-is the con- tra-stimulant treatment, to use Rasori's expression-that is to say, the admin- istration of antimonials, among which kermes ought to have the preference. The efficacy of bleeding, I repeat, appears to me, for the present, very open to be disputed. In respect of blisters, the employment of which has been very general, from an impression that they greatly accelerate resolu- tion of the inflammation, I concur with a large number of my professional brethren in thinking that, when the disease is at its height, they may in- crease the febrile excitement, and that when it is in a more advanced stage, 670 TREATMENT OF PNEUMONIA. they are useless. Moreover, during certain medical constitutions, a blister may be the starting-point of very severe erysipelas. It is, therefore, my practice to have recourse to kermes, or to kermes combined with digitalis. Not a week-indeed, I may say, not a day- passes, without your hearing me prescribe this medicine. Consequently, you are acquainted with my method of administering it. To avoid a drawback incident to its use when prescribed in the form of potion, a drawback depending upon its locally irritant properties, its caus- ing a pustular inflammation of the tongue, pharynx, and oesophagus, similar to that produced by rubbing the skin with tartar emetic, I give it in pills. I order a mass to be made of kermes, extract of digitalis, and medicinal soap [sawn medicinal*], dividing it so that each pill contains ten centi- grammes of kermes and one centigramme of the extract of digitalis. The patient ought to take from ten to twenty-five of these pills during the day, at intervals as nearly equal as possible. When they produce vomiting anol diarrhoea, I take care to give a drop of the laudanum of Sydenham with each pill, so as to establish a tolerance for the kermes. I continue this treatment during the whole of the acute period of the disease: when the febrile symptoms are subdued, I diminish the dose, but do not discontinue the medicine. From my adopting this method of administration, you never see a pus- tular eruption produced by the kermes. Here, gentlemen, we are brought into collision with the opinion of those who hold, with Laennec, that the appearance of pustules is indicative of saturation of the system with anti- monials, just as salivation and mercurial stomatitis are the results of satura- tion, infection of the whole economy, with mercury. Supposing that this opinion, from which I dissent, were a real expression of the facts, you would obtain this saturation as quickly by administering the remedy in pills as in potion; and again, mercurial stomatitis is quite as apt to supervene after mercurial frictions or baths, as after the internal administration of mercury. I again repeat-what you can daily verify for yourselves-that antimonials given in pills, be the dose what it may, never produce inflammation of the mouth, pharynx, and oesophagus, as they do in the form of potion, when they remain long in contact with the mucous membrane. Erysipelato-Phlegmonous Pneumonia. Gentlemen : I place before you the lungs of a patient who died from a special form of pneumonia, which I have called erysipelato-phlegmonous pneumonia. Let me tell you why I have given this name to the disease. Generally, as you know, simple inflammation of the pulmonary parenchyma runs a course precisely similar to that of a boil-in this sense, that attack- ing a greater or less portion of the organ, it is at once that which it is destined to be, or, at least, it remains localized in the parts which it first seized, exactly as a boil in the cellular tissue is limited to its original situa- tion. This form of simple pneumonia accomplishes its entire course of evo- lution, passing from the first to the second stage, and sometimes to the third: after which, resolution may take place, the patient recovering after having expectorated sputa to which pus imparts a characteristic aspect; or * Savon medicinal is made of two parts (by weight) of oil of sweet almonds and one part of caustic alkali. Castile soap [sat>o« dur], made of olive oil and soda, is also designated "savon medicinal."-Translator. TREATMENT OF PNEUMONIA. 671 the pus may collect, forming a real abscess, which may burst suddenly into the bronchial tubes. But the other form of pneumonia, which carried off the person whose autopsy we are now making, has not these simple characters. The paren- chymatous phlegmasia, instead of remaining confined to the situation in which it is originally developed, has a peculiar tendency to invade other parts; it migrates like phlegmonous erysipelas of the cellular tissue. In two words, here is what occurred in the case of our patient! Ten days ago, he entered the clinical wards complaining of a violent stitch in the right side, quite at the base of the chest. In the spittoon, we observed peripneumonic sputa of a slightly viscid character. The breathing was greatly oppressed, and there was high fever. Although these diagnostic data left no room for doubt as to the existence of pneumonia, I could not find, on auscultation, any physical sign of that disease. In no part, though the examination was made with the utmost care, could I hear rales or blow- ing. I then thought that it might be a case of pneumonia affecting a cen- tral portion of the lung, and foresaw that when the hepatization reached the surface of the organ, there would be produced the stethoscopic phenom- ena previously in vain sought for. In fact, at my second visit, I heard fine crepitation, in front, about the tenth rib. From that time, no characteristic sign of the lesion was wanting. On the following days, the physical signs indicated that the pulmonary inflammation was extending: it at first advanced to the middle of the axil- lary hollow, where it seemed to stop in its progress, there being at the same time observable a real amelioration in the totality of the patient's symptoms. The fever had abated, and he had even begun to feel some inclination for food, when the posterior part of the inferior lobe was attacked; and soon after- wards, the superior lobe became involved. The general symptoms, at the same time, became very severe: ataxic phenomena with delirium super- vened : and the patient died. Here, then, gentlemen, you have a pneumonia, apparently not at all serious at its commencement, very circumscribed, seeming on the first day to confine itself to a minute space, and even to show signs of incipient reso- lution : you have this pneumonia all at once redeveloping itself with more than its original violence, and within nine or ten days invading progres- sively the entire lung, exactly as we see phlegmonous erysipelas, at first limited to the extremity of a limb, progressively attack the whole member, and give rise to most formidable symptoms. This is one of the worst forms of pneumonia, one of the forms which baffles our means of treatment, in consequence of the constitution of the patient, exhausted by the successive shocks of the malady, being unable to respond to remedies otherwise most useful. Treatment of Pneumonia complicated with Delirium, by Preparations of Musk. Musk not indicated in all cases of Pneumonia accompanied by Delirium.- Distinctions Essential to establish in relation to this point. Gentlemen: You have seen me prescribe musk a second time for a patient, occupying bed 24 of our ward for women, who had a relapse of pneumonia. I must state why I have done so; and explain to you the circumstances in which I consider this medicine to be useful. In the first place, gentlemen, let me remark that musk is a medicine 672 TREATMENT OF PNEUMONIA. which I seldom employ in the treatment of pneumonia. Many months will probably elapse before a case occurs in which its use is indicated; but rare though these cases be, as they may present themselves and greatly embarrass you, it is necessary to make you familiar with them. It is in the forms of pneumonia accompanied by delirium, which were called ataxic and malignant by the old writers, that this treatment takes an important part. To Recamier belongs the credit of having in these later times assigned to it this honorable place. What ought we to understand by the expression ataxic pneumonia; or, to speak more accurately, what is ataxia in pneumonia ? Nervous disorders, delirium in particular, supervening in the course of diseases are insufficient to constitute ataxia. To have an accurate under- standing on this point, it is indispensable to distinguish several kinds of delirium in the pneumonia with the consideration of which we are now occupied. In the first place, there is that delirium which is dependent upon the intensity of the peripneumonic fever, and which only indicates that the brain participates in the febrile excitement of the entire organism. It is not of common occurrence, except during the night, when the patients are in a drowsy state ; it is, or may be, observed in all acute diseases accom- panied by fever, and it has no special character. Musk certainly would not produce any beneficial effect upon this kind of delirium, inasmuch as it has no power over the inflammatory peripneumonic fever itself, and because the delirium will only yield to the means which stop the fever. It is also necessary to recollect that there is a form of delirium occurring in persons of highly nervous temperament, which is not amenable to musk. It is well known that the persons who become delirious under the least febrile excitement are those in whom, a fortiori, inflammation of the lung excites very intense fever. Secondly, there is delirium connected with suppuration of the pulmonary parenchyma, probably similar in kind to all forms of delirium produced by purulent infection, and which is of evil augury-" a peripneumonia phrenitis malum," to use the words of Hippocrates. It is always unpropi- tious, irrespective of the extent of the pneumonia. It is not amenable to musk. Thirdly, there is delirium caused by one or several inflammatory com- plications situated in other parts than the lungs, and apt to be mistaken by the practitioner. It belongs to the first variety. Fourthly, there is a delirium more dependent upon the malignity of the cause than upon the pneumonia itself. It is met with in pneumonia pro- duced by poisoning, both in cases resulting from poisoning by articles of the Materia Medica or from morbific atmospheric miasmata, and by morbid poisons engendered within the economy. In all such cases, the pneumonia and the delirium are effects of the same cause. This is apparent in the pneumonia which complicates putrid fevers, acute glanders, &c., &c., and poisoning with acrid substances. In this class of cases, there is no indica- tion for the use of musk. Finally, there is a species of low delirium, attended by a want of harmony between the different symptoms, and a predominance of nervous phenomena bearing no evident relation to the inflammation of the lung. Under the influence of autiphlogistics or antimonials, this ataxic state increases. Were we to judge only by the diagnostic signs derived from stethoscopic and plessimetric examination, we should say that the pneumonia is not serious, and yet the vital power, prostrate and disorganized, collapses sud- denly, and the patient dies. This is ataxia-this is malignity. TREATMENT OF PNEUMONIA. 673 The characteristic of this species of delirium is the impossibility of asso- ciating it with any known material condition of the solids or fluids. In cases of this description, it would be a loss of time to seek for the cause. This kind of ataxia shows itself, I repeat, by want of harmony between the local and general symptoms, and also by want of harmony between the different functional disorders, which ordinarily progress parallel with one another, or are correlatives. Let me explain myself. An individual has a very slight attack of pneumonia: let us suppose that the disease is prevailing as an epidemic, so that a certain number of per- sons become affected in a manner similar to him. While in none of those seized, excepting the first mentioned, do nervous symptoms supervene, or at least if present, are proportionate to the extent of the lesion, in the in- dividual first mentioned, there is delirium from the very first, without the inflammation having attained such a height as to justify one in supposing that the intensity of the inflammation is the cause of the nervous symptoms, and without the phlegmasia reaching the stage of suppuration, which if present, as I have just said, would explain the delirium. It thus becomes necessary to admit that in the individual first mentioned, there was a pecu- liar modality of the nervous system in virtue of which the nervous centres showed evidence of disorder not explainable by the slight local lesion. This is a point of the first importance. In the second place, there is want of harmony, parallel or correlative, between the functional disorders. In pneumonia-in peripneumonic fever -proceeding regularly, at the same time that the pulse becomes very quick, respiration becomes relatively accelerated. For example, while the pulse rises to 120 in the minute, the respirations are from 36 to 40: here the dis- orders of respiration respond to those of the circulation. This is what takes place in ataxic pneumonia. In the woman whose case is the subject of the present lecture, I insist upon this point, and beseech you not to forget it: while the pulse was 84 in the minute, the respiratory movements rose to 88. Respiration, conse- quently, had a frequency quite out of proportion to that which it generally bears to the arterial pulse. In place of being about one-third slower than the pulse, it was quicker than the pulse. There was consequently a want of harmony between the functional disorders, which generally proceed in a parallel course. It may also happen, gentlemen, that the want of harmony which char- acterizes ataxia is not so great in respect of the respiratory or circulatory functions viewed in relation to one another, as in respect of the two when compared with the nervous symptoms. Thus, along with the delirium, there may be no great frequency in the respirations, and-judging by the pulse and the temperature of the skin-the fever may be very moderate. Under what circumstances, and in what class of patients, is this peculiar form of delirium met with ? It is met with more frequently in women than in men, which is easily explained by the fact that disorder of the nervous system is more common in the former than in the latter. In men addicted to alcoholic liquors, or who drink stimulants to excess, it is also more usual than in others. In this class of patients, the nervous symptoms of which I speak occur not only in connection with an inflammatory affection such as pneumonia, but like- wise as a consequence of severe traumatic lesions, such as a compound fracture of one of the extremities, a serious injury of a joint, or, it may be, after even a slight surgical operation. In telling you this, I am not stating anything which you have not already learned from your surgical teachers. Have you not heard them say a hundred times, that persons who have re- vol. i.-43 674 TREATMENT OF PNEUMONIA. ceived wounds, have been surgically operated on, or have abused alcoholic liquors, are liable to a peculiar form of delirium, tremens? Now, this delirium is analogous to the nervous symptoms to which I am at present directing your attention. It is liable to occur in the same persons in the course of a pneumonia, just as in the course of any other inflammation, or during a fever. This delirium of drunkards, however, differs in its nature from the delirium which more specially characterizes malignity. It is a purely nervous delirium: the brain is in a state of violent excitement: the patients are restless, they wish to get out of bed, they talk nonsense with furious vivacity, just as if they were in the excitement stage of alcoholic intoxication; but there is no prostration of the vital powers as in ataxia. If you employ musk to subdue the delirium of fever, or of suppurative pneumonia, if you employ it in cases in which the nervous symptoms de- pend upon the malignity of the cause which dominates the pulmonary in- flammation itself, you mistake the indication, and your treatment is inevit- ably a failure. The consequences of your error will be disastrous. You will be prevented from recognizing in musk the beneficial effects, which, when given in suitable cases, it is capable of producing; and will, therefore, not administer it in cases in which you ought to give it and obtain from it the best possible results. Michael Sarcone proved the reality of these marvellous results, when, by the treatment I now commend, he checked delirium and disastrous excita- bility in some of his patients during the terrible Neapolitan epidemic of which he has left us a history remarkable from many points of view. He says: " When there was a threatening of delirium, and when in the aggregate of symptoms, there was a manifest sensitiveness, along with insomnia and great disorder of the nervous system, the only appropriate remedies were those which afforded quiet and repose to the patient. It is impossible to speak too strongly of the advantage obtained in these cases by the use of gentle calmatives and narcotics, when judiciously given. Musk was especially remarkable for its great efficacy in calming and subduing a tendency to convulsions which was dominant in a very marked degree in some of the patients. They at once fell into an agreeable and unhoped for torpor, and then by degrees passed into a state of repose, into drowsiness, and into sleep. The pulse acquired a more equal volume ; and the respi- ration became less sighing. In cases in which delirium was not prevented, it was certainly less violent than had been threatened by the severity of the symptoms: and it never attained such dangerous manifestations in those to whom this drug was administered, as in other patients from whom it was withheld, or too long delayed, owing to I know not what preju- dices."* Gentlemen, let us have no misunderstanding on this point. I do not give musk indiscriminately in the delirium of pneumonia any more than I do so, in that of scarlatina or small-pox: I only give it in that peculiar form, which, manifesting itself in maladies characterized by nervous dis- order, are yet not of a serious nature. In these cases, musk becomes a sort of regulator of the nervous system, which then responds in a regular manner to the assaults of the disease. What occurred in the case of our patient of bed 24 St. Bernard's Ward? From the second day of her pneumonia, this woman was delirious, though the local affection remained very limited in situation, and did not pass * Sarcone : Histoire des Maladies Observees a Naples, t. ii, p. 240. TREATMENT OF PNEUMONIA. 675 beyond the second degree. The respirations rose to 88 in the minute, although the pulse was only 84. The ataxia w7as evident: the indication for giving musk was precise. Whilst I administered it, however, I did not discontinue giving the kermis. With kermds I combated the inflam- mation, while I at the same time directed the antispasmodic remedy against the nervous element of the disease. You have seen the results of this treatment. No doubt, on auscultating the chest, you have satisfied yourselves that it has not stopped in any de- gree the inflammation of the lung. I made no such pretension; for, treat- ing the case by antimonials, or by bleedings, the indications for employing which are, as I have already said subordinate to the dominant medical constitution, we may conduct the pneumonia to its termination in resolution, but we cannot cut it short in twenty-four, thirty-six, or forty-eight hours, as has been supposed possible by some physicians. I therefore waited to see the local affection run its course; but I also waited to see the cessation of the nervous symptoms. The respirations fell from 88 to 44 in the minute, although the pulmonary lesion, being a little more extensive than before, one might on the contrary have expected acceleration of the breath- ing, had that been dependent upon the state of the lung. Although the number of the respirations had not yet come down to the normal standard, there was every reason to hope that this diminution would take place on the following day. The very violent delirium, which might have caused anxiety, had calmed down: during the night there was only a little restlessness, and in the morning, the patient answered questions with precision. The musk had induced this sedative effect, though I had not had occasion to give more than 50 centigrammes in the twenty-four hours. I still continue to use it. As the patient has been entirely without sleep during the last three days, and as this insomnia is a phenomenon pertaining to ataxia, I shall, if it continue, combine small doses of opium with the musk, or 1 shall give the opium by itself. The combination of musk and opium is also recommended by Sarcone, when there is exhausting obstinate sleeplessness in addition to the other nervous symptoms. But it is not enough to be able to recognize the indications for giving musk in pneumonia accompanied by delirium-there are certain rules connected with its administration, which it is indispensable to know. It may be prescribed to the extent of a gramme a day divided into ten doses given in the form of pills, one pill being taken every hour till there is a remission in the ataxic symptoms, which generally occurs within eight or ten hours. At the end of that time, according to Recamier, if no benefit has been obtained, we need not look for results, as they are either obtained promptly or not at all. I have still a word to say, in conclusion, regarding our patient. Her pneumonia is not extensive, and the reactional symptoms, separated from the nervous symptoms, also indicate that the case is not serious. Under the circumstances, therefore, I consider that in this case recovery will take place.* Gentlemen, I think it very important to bring these points under your notice, and to state with precision the indications for the treatment which you have seen me employ, because I have often heard its efficacy called in question by very worthy persons, who have unsuccessfully employed musk in pneumonia with delirium. Their failure did not depend on the remedy * After having been under treatment for some days, this woman made a com- plete recovery, and was able to leave the hospital. 676 TREATMENT OF PNEUMONIA. being bad, but on its having been given in unsuitable cases, in very different forms of delirium from that now under our consideration. By such errors in diagnosis the character of the best therapeutic agents is compromised. When you confound with one another the different phenomena which may supervene in the course of a disease, you inevitably fail, through attacking symptoms which are not the same by the same remedy. The remedy hav- ing failed, from its employment not having been indicated, you cannot see its utility, and you deprive yourselves of a powerful agent, which in appro- priate circumstances is of real service. Pneumonia of the Summit. Not necessarily accompanied by Delirium.-Delirium may also occur in Pneu- monia situated in the Centre or Base of a Lobe.-Pneumonia of the Sum- mit is not necessarily more dangerous nor more tedious; but this statement requires limitation in respect of Tuberculous Patients. Gentlemen : In beds 4 and 18 of St. Agnes's Ward you have seen two men with acute simple pneumonia. Both these men, who are of good con- stitution, in the prime of life and under thirty, took the disease which brought them to the hospital, in the way which is most usual, that is to say, in consequence of a chill. In both there was this peculiarity, that the pneumonia occupied the summit of the lung. Both recovered completely and rapidly: no complication arose to impede the cure. Let me briefly recapitulate the facts. The first subject had been ill for seven days: a violent shivering fit and a stitch in the side announced the beginning of the morbid symptoms: almost immediately afterwards there supervened cough, accompanied by expectoration. The fever, which forthwith declared itself, has continued ever since. When this patient came into hospital on the third day of the disease, we found him expectorating characteristic sputa of a saffron yellow color, aerated, viscid, adherent to the vessel, and leaving no room for doubt as to the diagnosis. The harshness of the sound elicited on percussing the left side of the chest over the infraspinous fossa of the scapula and under the clavicle, the crepitant rales and the blowing sound of expiration per- ceived on auscultation of these regions, confirmed the view already satis- factorily arrived at, as to the nature of the case, from an inspection of the sputa and the symptoms complained of by the patient. We had pneumo- nia, and that pneumonia was situated in the summit of the left lung. Next day the blowing expiratory sound had given place to tubal blow- ing, and numerous puffs of fine crepitation were heard throughout a space more extended than on the previous evening. On the sixth day the stetho- scopic signs were still more decided. Contrary to what I have frequently observed this year, the patient com- plained of obstinate constipation, although he had been taking kermes in large daily doses. I found it necessary to give him two calomel pills, each pill containing five centigrammes; and in addition to this,two grammes of powder of jalap. These remedies produced the desired effects. This morning-the eighth from the beginning of the malady-I find the patient without fever, the skin is in a good state, the pulse is full and not quick, its amplitude being proportionate to the constitution and strength of the subject. The stethoscopic signs are modified, and we now hear the vesicular murmur^accompanied it is true by fine subcrepitant mucous rales, TREATMENT OF PNEUMONIA. 677 in situations where, forty-eight hours previously, we heard tubal blowing and crepitant rales. The resolution of the pneumonia has, therefore, fairly begun. Yesterday, however, a circumstance arrested my attention, although the condition of the patient seemed satisfactory. I refer to the character of the sputa. The saffron color which they presented during the first days of the illness had become of a deeper shade ; and yesterday, though still retaining their viscid character, they had assumed the aspect of wine lees, or prune-juice, gener- ally an evil omen. As, however, the sputa were still viscid, I was less alarmed by their change of color. In point of fact, it is not so much the sputa assuming the prune-juice color in peripneumonia, as their ceasing to be viscid, and assuming a peculiar diffluent character, which constitutes the unfavorable prognostic. This morning we observed that the sputa had re- assumed a slight saffron tint, and were not profuse. The history of our second patient is nearly identical with that of the first. His peripneumonia, contracted under similar circumstances, occupied the same situation, ran the same course, and likewise terminated as rapidly in recovery. In both cases, my treatment was the same : I employed antimonials: I had recourse to kermes. These cases form an appropriate sequel to what I have been saying on the use of musk in pneumonia. In fact, gentlemen, the form of delirium so remarkably subdued by that remedy, is perhaps most frequently met with in pneumonia of the summit. The reason of this I cannot tell; but the fact is generally admitted. It is evident, however, that pneumonia of the summit does not necessarily induce nervous symptoms ; as is proved by the cases of the two men of St. Agnes's Ward. You also learn from these two cases that pneumonia of the summit is not inevitably more serious than pneumomia of the base. I do not deny that in persons of the tuberculous diathesis, pneumonia of the summit is a more serious affection than in those not under that diathesic influence. This does not depend upon the pneumonia itself, but upon the risk there is that its presence may hasten the development of phthisis, by calling forth the manifestation of the diathesis by accelerating the evolu- tion of tuberculous products in their favorite seat-the summit of the lung. With this limitation, I maintain that pneumonia of the summit is not more dangerous than pneumonia of the base or centre. The gravity of the inflammation does not depend upon its situation, but upon its extent and nature. With regard to extent: a pneumonia which simultaneously invades an entire lung is, if other conditions are equal, more grave than inflamma- tion limited to one lobe, and double is always more dangerous than single pneumonia. With regard to nature: the relative gravity, I should say, depends on the specialty of the nature, which varies with the epidemic constitution, the previous condition of the patient, as well as with certain other influences, an intimate acquaintance with which we are unable to obtain, and which we know only by their effects. 678 PARACENTESIS OF THE PERICARDIUM. LECTURE XXXVII. PARACENTESIS OF THE PERICARDIUM. Cases.-Historical Summary.-Harmlessness of Tapping the Pericardium and injecting Solutions of Iodine.-Better to make the opening with the Bis- toury than with the Trocar.-Dropsy of the Pericardium almost always associated with some other diseased state, particularly with the Tubercu- lous Diathesis.-Paracentesis affords relief and prolongs life placed in immediate j eopardy. Gentlemen : In your presence, I performed paracentesis of the pericar- dium upon a patient who lay in bed 2 of St. Agnes's Ward. The man died five days after the operation; and I placed before you the morbid structures found at the autopsy. This patient was a young man of 27, who came into our clinical wards on the 2d June, 1856 : he dated the commencement of his illness from a few days prior to his coming into hospital. I observed at my first visit, that there was great oppression of the breathing: throughout nearly the whole of the chest, I heard sibilant, mucous, and subcrepitant rales-in fact, all the signs of capillary bronchitis. The intensity of the fever quite corresponded with the severity of the local symptoms. This young man told us that two years previously he had had a severe pulmonary affection, for which he had taken cod-liver oil. I prescribed preparations of antimony and digitalis: I administered pur- gatives : speedy improvement was the result. I did not, however, take into account the persistence of the fever, still less the persistence of the peculiar anxiety experienced by the patient. Upon afterwards carefully examining the heart, I heard a blowing sound ; and also a friction-sound accompanying both sounds of the heart, a little more marked at the apex, which is not usual in pericarditis, in that disease the double friction-sounds being heard around the base of the heart: in other respects, the pulsations were perfectly distinct. This young man had never had rheumatism. My opinion was that there existed endocarditis, and a lesion of the mitral valve complicating the pulmonary catarrh. Once my attention was called to this point, I carefully auscultated the heart every day. A week had scarcely elapsed, when the stethoscopic phenomena presented a strange modification. I distinctly heard a double- bellows sound at the apex, and some days later there was a reduplication of the second sound, so as to constitute a third sound, called the bruit de rappel or bruit de galop. The precordial dulness increased greatly, the blowing sounds became more and more distant from the ear, and at last were hardly audible. The pulsations of the heart became very obscure, and then ceased to be heard. The pulse at the wrist continued to be rapid, but it was regular, and of fair strength. There was no doubt as to the existence of the pericarditis, the progress of which I followed. The arching of the precordial region, the limits of PARACENTESIS OF THE PERICARDIUM. 679 the dulness-extending to the right beyond the median line, and reaching on the left to two or three centimetres external to the nipple, descending as far down as the diaphragm, ascending to the third rib, thus circumscribing a space of about twenty centimetres-clearly indicated the existence of extensive effusion into the pericardium. The anxiety of the patient increased proportionately to the increase of the pericardial dropsy, although in respect of the cough there was a great change for the better. No amelioration of symptoms was obtained by the administration of digitalis, calomel, and purgatives, and the application of blisters to the region of the heart. Matters had been going on in this way, or getting worse, for six weeks; when I perceived cedema of the extremities, puffiness of the face, and great paleness of the skin. These symptoms suggested that there was probably albuminuria; but upon analysis of the urine it was found not to contain any albumen. I then concluded that the anasarca, oppression, and anxiety were all dependent upon obstructed circulation. The pulse had become small and very rapid. Under the circumstances, I considered that paracentesis of the pericar- dium was indicated. I nevertheless allowed a fortnight to elapse; for although two years previously, in my wards, I had operated successfully in a similar case, I hesitated to have recourse to an operation which one never without trembling decides upon performing. The symptoms, however, became so urgent, and death appeared so imminent, that I determined to delay no longer. On the 1st August, I invited my colleagues of the Hotel- Dieu to meet me in consultation on the case. I submitted to my colleagues the triple question of diagnosis, prognosis, and treatment. They were all of opinion that there was pericarditis with effusion, which was estimated at less than a litre. They all thought, that, looking to the anxiety of the patient, the general puffiness, and the ex- treme paleness of the tissues, death would occur within a few days. They likewise all thought, that although the operation offered but little chance of success, that the treatment which afforded the greatest chance was the prompt evacuation of the fluid by tapping. Paracentesis having been decided on, I forthwith proceeded to perform it. I employed a bistoury in opening into the chest. The incision was made in the centre of the circumference marked out by dulness, below the nipple, and in the nearest intercostal space. After cutting in succession, with the utmost caution, the skin and muscles, I reached the pleura. This meinbrane was next cut through. Upon introducing my finger into.the cavity of the chest, I encountered resistance from the distended pericardium. I did not feel the heart beating under my finger. I then cut through the successive layers of tissue, separating them by means of a grooved director. At last, the point of the bistoury having penetrated a little too far, some slightly red serosity spurted along the blade. Using the grooved director, I enlarged the incision only to the extent of half a centimetre: a gush of similar fluid then issued from the wound, and in part spread under the layers of tissue: nearly 100 grammes were collected in a pallet. This fluid immediately coagulated like currant jelly: the flow then ceased. I intro- duced several gum-elastic sounds, but by so doing did not succeed in ob- taining any more fluid. By causing the patient to be placed on his left side, nearly 200 grammes of yellow-colored serosity issued from the open- ing; this, therefore, was very different from the first-drawn serosity, which, when received in the same pallet, coagulated but imperfectly, and con- 680 PARACENTESIS OF THE PERICARDIUM. trasted by its amber color with the appearance of red currant jelly pre- sented by the other. Gentlemen, it was seen, at the autopsy, that one of these fluids must have come from the pericardium, and the other from the pleura. From the cessation of the flow, I thought that the pericardium was occu- pied by false membranes, which retained the fluid within inclosures. I tried to inject a solution of iodine, but none of it passed into the cavity of the pericardium : perhaps about a tablespoonful penetrated into the pleura. The wound was then closed by means of diachylon plaster. Notwithstanding the small quantity of fluid withdrawn, certainly not more than 400 grammes, including both that which came from the peri- cardium and the pleura, the patient was decidedly relieved by the operation. The pulse became slower and fuller. Some air entered the chest during the operation: and mixing with the serous fluid which was withdrawn, gave it a frothy appearance. On aus- cultating the patient after the dressing, we heard the sounds of the heart unaccompanied by the mill-wheel sound [bruit de roue de moldin'], which has been given as a characteristic sign of hydropneumo-pericardial disease. The young man, who formerly could only lie on the left side, now found that he was most comfortable when on the right side. Matters went on pretty well till the afternoon : but when M. Beylard and I saw the patient about four o'clock, we found him in a very excited state, with high fever, and a pulse of 124. About three hours after our visit, he was suddenly seized with an attack of eclampsia: the convulsions were confined to the right side of the body. During the night, the attacks recurred every half hour. On the following morning, the right side of the body and the tongue were completely paralyzed ; but, strange to say! during the attacks which I witnessed, consciousness remained to a certain extent. The patient tried to answer questions; and with the left hand he pressed the convulsed mus- cles of the right cheek, to restrain their disorderly movements. Gentlemen, before I go any further, let me try to explain these attacks of eclampsia. Ought they to be attributed to the operation? Let us for the present leave out of view the question of the advisability of the opera- tion-a question resolved in the affirmative by my colleagues in the Hotel- Dieu and myself. Let it be granted that surgical interference was as rash a proceeding as could have been adopted, still, it was not one of those great surgical operations-those serious traumatisms-which sometimes in- duce nervous symptoms. Again, in the convulsions of our young man, there was nothing like the phenomena of tetanus. Let it be granted that the paracentesis increased,the intensity of the inflammation of the pericardium : but then, do inflamma- tions of the serous membranes, be they ever so violent, or whatever may be the extent of the membranes involved-do they usually lead to such symptoms? The answer is obtained by an appeal to clinical facts. Never does the most violent pleurisy, never does the most acute peritonitis fol- lowing perforation or strangulation of the intestine, induce convulsions- not at least in adults. Have you ever heard that it wras otherwire in peri- carditis ? The circumstances in which the patient was placed gave us a better ex- planation of his symptoms. You are aware that general anasarca, even when there is no albuminuria, produces a peculiar predisposition to eclamp- sia. This is observed principally in pregnant women and in children. A feverish attack or a mental emotion maybe the immediately exciting cause. You know also how much an anaemic condition conduces to the occurrence of convulsions. In our young man, two predisposing causes, anasarca and PARACENTESIS OF THE PERICARDIUM. 681 anaemia, existing in a high degree, it is not surprising that mental emotion occasioned by the dread of the operation-for he was much alarmed by the meeting in consultation held around him-should have induced the nervous symptoms of which I speak. I prescribed preparations of musk and valerian; and for the time,they seemed to subdue the symptoms. I was beginning to hope that matters were taking a favorable turn, and no new heart symptoms had occurred, when the respiratory organs were again attacked. On August 4th, the fourth day after the operation, I observed more oppression of the breathing, as well as some cough accompanied by profuse expectoration of slightly viscid matter; and I heard subcrepitant rales. Next morning, these symp- toms had become still more alarming, and caused me much more anxiety than those referable to the heart. From the very weak state of the patient, I was unable to examine the chest as carefully as I should have wished. However, the dulness of the precordial region indicated that there was still a very considerable amount of effusion, though much less than before the tapping. The patient died on the evening of Tuesday, 5th March, five days after the operation. The autopsy was performed with the greatest possible care. The ribs on the left side, from the axilla to the base of the chest, were sawn through : on the right, the sternum was separated from the costal cartilages, then the sternum and anterior part of the chest were detached in such a way as to remove the trachea, the lungs, and the heart intact within the pericardium. In the left pleura, I found a citrine-colored fluid similar to that which flowed during the second period of the operation. There were neither false membranes, fibrinous flocculi, nor adhesions. The pericardium was reddish in color, and resembled an enormous globe as large as a man's head. It had no adhesions with the ribs, and was only in its upper part covered by a thin portion of the left lung, which was firmly attached to it by an adhesion of old date. Situated in the anterior mediastinum, which it had separated, it resembled a fruit planted behind the sternum on a large base, and floating in the pleural cavity which it had opened. Almost opposite the point at which the opening had been made in the intercostal space, a violet spot was observed on the inside of the pericardium-the mark left by the cut of the bistoury. The blunt end of a probe entered it easily. The false membrane which lined the serous membrane in the situation of this opening was red, apparently from recent sanguineous effusion. On opening the pericardium, there flowed out nearly a litre of a reddish fluid, identical with that collected in the pallet during the first part of the operation. A very few fibrinous flocculi were observed floating in this fluid. The heart was at the bottom of this sac, at least ten centimetres from the wall of the cyst, and from the point where the puncture had been made. It was covered by a thick, reticular, dirty-yellow false membrane, as was likewise the whole of the interior of the sac. The thickness of the wall of the cyst might be about five millimetres. On cutting the heart, it was found that below the serous coat there was a thick lardaceous cellular tissue, resembling a layer of fat. The heart was of rather more than the natural volume: but the hyper- trophy was concentric, the cavities being narrower than normal. The flap of the valve was supple, thin, and without appreciable change of structure. The orifices, however, allowed the finger to pass less easily than in a healthy heart. In the lungs and bronchial glands, there were disseminated both crude and softening tubercles. Near the pancreas, there was a mass of softened 682 PARACENTESIS OF THE PERICARDIUM. tuberculous glands. The mesenteric glands were engorged. There were some intestinal adhesions. In the encephalon, the only morbid appearance seen was a little soften- ing of the falx cerebelli. It ought, however, to be stated, that the autopsy was made during very hot weather. The post-mortem examination gave us complete information as to what took place during life, and during the operation. There was pleural as well as pericardiac effusion. The stoppage in the flow of the pericardiac fluid was produced by a mechanical cause which is easily explained. Once I had penetrated the pleura, I was afraid to go farther, and consequently only made a very small opening in the pericardium opposite the opening in the thoracic walls. The parallelism between the two openings was soon destroyed, and the result was the flow of the pericardiac effusion into the pleural cavity. Could I have avoided this accident by at once introducing a sound into the pericardium through the opening made by the bistoury, or by punc- turing with a trocar so as to enable the fluid to flow through the canula ? But even then, there would have been difficulty in avoiding the inconveni- ence which arose from the fluid oozing out between the lips of the wound and the sides of the canula : as soon as the canula was withdrawn, the parts resumed the vicious position which it was supposed could have been pre- vented. When I come to discuss the mode of performing paracentesis of the peri- cardium, I shall return to this question, to explain how it is that the incon- venience referred to is, in my opinion, a matter of small importance. Then, I shall also tell you, why I prefer to operate with the bistoury, and not with the trocar employed by others, and in particular as you have seen it used even in my wards, in the case regarding which I have now been speaking. Finally, I shall have to tell you that I reject Riolan's operation, adopted by Skielderup and recommended by Laennec, which, consisting in pene- trating into the pericardium by trepanning the sternum, is a proceeding which seems to me at the least to be useless. Gentlemen, as I have just mentioned, I have had occasion to perform paracentesis of the pericardium in the case of a young man in our wards. This first case (published by my friend Dr. Lasegue and me in the Archives Generales de Medecine for November, 1854) might have been considered as encouraging. The patient, a lad of sixteen, was admitted to St. Agnes's Ward on the 2d February, 1854. He was pale and weak ; but he declared that he had never had any serious illness. Four or five days before he came into the hospital, he had suffered from very severe frontal headache, which was soon followed by extreme lassitude and pain in the precordial region. On admission, he had intense dyspnoea: his pulse was 150: he had a little cough: and there was an expression of suffering in his countenance. On percussion, I found great dulness in the region of the heart, reaching as high up as the second rib, and extending from the right margin of the sternum to very far forward in the left side of the chest, in which direction, however, its limits could not be exactly defined : posteriorly, the left was less sonorous than the right side of the chest: the sound of the pulsations of the heart was obscure and distant. The patient had never completely fainted ; but had a constant feeling that syncope was imminent. I ordered a large blister to be applied to the precordial region ; and prescribed an infusion of digitalis as a tisane. During the month of February, while the pulse continued very rapid, the pulsations of the heart were better heard at intervals, becoming, how- PARACENTESIS OF THE PERICARDIUM. 683 ever, indistinct at other times. The dulness in the precordial region occu- pied almost uninterruptedly a space extending upwards and downwards of seventeen centimetres, and transversely of eighteen centimetres: during two days only-from the 18th to the 20th-did it appear to diminish. At this time, there was a double cardiac friction-sound, which was most appreciable at the base of the heart. The arching of the precordial region became more and more marked on the left side of the chest: the signs of pleural effusion became more and more distinct, there being posteriorly, below the scapula, aegophony and a bellows-sound. On the 17th March, it was noted that the arching had been greater for eight days, and that profuse diarrhoea had supervened. The patient was losing strength and flesh, and could no longer move in bed without induc- ing a tendency to faint. The face was pale and livid: the oppression of breathing was extreme: respiration was short and sighing: percussion, and even the simple application of the hand over the precordial region, produced pain and pang: the pulse, small and feeble, was 120: the dulness extended up to the clavicle. Next day, in consequence of the symptoms having become more serious, and death threatening, I resolved to have recourse to paracentesis of the pericardium. Professor Jobert (of Lamballe) operated. In the fifth inter- costal space, at about three centimetres from the left margin of the sternum, he made an incision through the skin and cellular tissue to the intercostal muscles. He then introduced slowly, steadily, by continuous pressure, ob- liquely from right to left, a trocar provided with a piece of membranous material. On withdrawing the stem of the instrument, some drops of reddish serosity flowed through the canula. When the canula was left free in the wound, it was moved about by the action of the heart, being raised up by each contraction of the organ. During the operation, the patient (who had requested its performance but was alarmed by the preparations) was pale, and groaned, His pulse, very slow and almost imperceptible, ere long regained its usual strength and quickness. He had no feelings of general discomfort, no great amount of oppression, and no faintness. At first, the fluid flowed pretty freely, although it did not spurt out in a jet. When about sixty grammes had been collected, the flow became slower: the canula was then fixed in the wound, whereupon, without favoring the flow by any manoeuvre, the fluid dribbled out. The operation was per- formed at nine in the morning: at half past nine, the patient stated that he neither experienced any relief, nor felt increased oppression. The canula was removed at half-past ten: by that time, the flow amounted to 400 grammes. About noon, the young man felt a little better. At my evening visit, he expressed himself as having obtained great relief. He breathed quietly. His pulse was 134, and full. The dulness only extended upwards to within four finger-breadths below the clavicle, anol did not go more than two centimetres to the right of the middle of the sternum : on the left, it extended to a line drawn vertically downwards from the anterior boundary of the axilla. The pulsations of the heart were much more distinct; and the apex of the heart was appreciably raised. Forty-eight hours later, the report made was to the following effect: the ameliorated condition is maintained: there is increased-almost tympanitic -resonance anteriorly in the left summit: the respiratory murmur is audi- ble from the clavicle to the fourth rib, where dulness commences: the sounds of the heart are becoming more and more distinct: on the left side, poste- riorly, there is dulness, bellows-sound, and jegophony: there is little cough, and almost no oppression of the breathing; there is not much fever. 684 PARACENTESIS OF THE PERICARDIUM. On the 22d March, the pleuritic effusion was progressing: the heart was pushed over to the right side, and there was great distension of the left side of the chest. The patient lay on the right side, and complained of an exceedingly painful stitch. Up to the end of the month, the pleuritic effusion went on increasing; the fever augmented ; and the cough, more frequent, was accompanied by the expectoration of thick white matter. Mucous rales were heard at the summit of the left lung. The oppression of the breathing had become more decided, but still it was not nearly so urgent as it had been before the operation. There was some diarrhoea, which was moderated by the administration of nitrate of silver. On the 30th, seeing that there was effusion occupying the entire left pleura of an individual already exhausted by his disease, I did not hesitate to per- form paracentesis of the chest. A first opening made in the sixth inter- costal space, in the axilla, did not afford exit to one drop of fluid: the trocar had been arrested by a very tough false membrane. A second opening, made a little more posteriorly, and lower down, allowed about 500 grammes of fluid to flow out. The operation was not followed by any par- ticular occurrence, and did not occasion any untoward symptoms. On the 2d April, some subcrepitant rales were heard in the lower part of the left lung; but there was neither blowing sound, eegophony, nor any appreciable embarrassment of breathing. The diarrhoea continued. The patient had insomnia. From the first days of April, up to the 28th May, the day on which the patient left the hospital, there was no reproduction of the pleuritic or peri- cardiac effusion. The pulsations of the heart could be felt by the hand: the sounds of the heart were not accompanied by any blowing or friction- sounds. The extent of dulness was greater than in the normal state: the arching was quite obliterated ; respiration was fairly free, and the young man made no complaint of dyspnoea. He sat up in bed to play, had appe- tite for food, and declared that he was very much pleased with his improved position. His general state, however, was far from satisfactory: his cough was more frequent: he had recurrence of the fever, particularly towards even- ing : the diarrhoea, more moderate it is true, was not yet checked: and he did not regain strength, notwithstanding the use of medicinal tonics and a strengthening regimen. As he was weary of the hospital, and attributed the slowness of his con- valescence to his remaining so long, he asked to be allowed to leave. The signs of tuberculization, which had been becoming more evident for a month, were quite decided at the date of his leaving the hospital. The symptoms then noted were the following: At the summit of the left lung, anteriorly, there were observed dulness, sibilant rales, gurgling during forcible inspiration, and an absence of the bellows-sound; posteriorly, at the summit, there existed subcrepitant rales, and at the lower parts of the lung there were mucous rales. On the right side, respiration was puerile in front: behind, expiration was blowing, the voice resonant, the rales dry and sonorous, and the pulsations of the heart were strong and distinct. The fits of coughing recurred unaccompanied by any special expectoration. The patient had dyspnoea, obstinate diarrhoea, emaciation, and Hippocratic deformity of the fingers. Notwithstanding his feeble state, he was able to be taken home in a car- riage to his family, in the department of Eure-et-Loir. During the first fortnight of June, we heard that his state continued very much as when he left the hospital. Since then I do not know what has become of him. PARACENTESIS OF THE PERICARDIUM. 685 This case, gentlemen, as I have already said, is an encouragement to per- form paracentesis of the pericardium, because it is an example of the opera- tion preventing death otherwise imminent. In one of my recent lectures, when giving you a rapid historical sketch of paracentesis of the chest in pleuritic effusions, I showed you that although the indications for operating had not been formulated with precision, the operation had been performed at different periods anterior to our own. Long before any one ventured to perform it, it had been considered from a theoretical point of view, and supported by sound arguments, as a proceed- ing likely to be useful and quite free from danger. It was not so in respect of paracentesis of the pericardium. A long period elapsed before it was advocated on speculative grounds; and while some expressed an opinion that it might be possible to operate for effusions into the pericardium as had been done successfully for effusions into the pleura, the proposal to bring a cutting instrument near so delicate an organ as the heart was re- jected as inexcusably rash. To Senac is generally attributed the honor of having pointed out the possibility of successful paracentesis of the pericardium;* but a century previously, Riolan had formulated the indications for resorting to that operation.! Senac certainly never performed the operation, though some compilers have made a statement to the opposite effect. Several authors cited by Sprengel, taught that the operation ought to be tried, as, if left to itself, dropsy of the pericardium must prove fatal; but they did not venture to set the example of performing it. Ricter, while he admitted its utility, exclaimed: " Intrepido opus est animo acl talem operationem instituendam and Van Swieten, who was not overtimid in employing remedies of risk in extreme cases, does not speak more confidently: he says, " Quam audax facinus dehet videri omnibus si quis cogitaret de pertundendo pericardia dum hydrope turget" However, notwithstanding the difficulties with which the diagnosis of dropsy of the pericardium was surrounded, although experience had not yet pronounced its decision, he recognized that it was allowable, rather than leave the patient to the cruel alternative of death, to afford by operation an outlet for the effused fluid: his words are, "Interim generate axioma practicum omnibus probatur: tentandum esse potius anceps remedium quam nullum, dam certa pernicies imminet." He concludes his remarks by describing the manner in which the operation ought to be performed. About the same period, Benjamin Bell, Camper, Arneman, and Conradi all recommended the operation to be tried, while they proposed different methods of operating, to the consideration of which I shall afterwards re- turn the counsels which they give are, however, purely theoretical. At a later date, Desault, who originally regarded paracentesis of the pericar- dium as almost impracticable on account of the difficulty of determining the indications, found a case in which he thought he had a good oppor- tunity of carrying out practically the precepts of his contemporaries: but his first operative attempt was far from being a success. The effusion, in fact, which he had desired to evacuate by tapping, was not contained in the pericardium, as appears by his account of the case, which is given with the most perfect simplicity and candor.§ This case, then, usually quoted as the first in which paracentesis of the pericardium was performed, has no claim to figure in the history of that * Senac: Traite de la Structure du Coeur etde Ses Maladies. Paris, 1749. f Riolan: Enchiridion Anat. Lib. III. Lugduni Batavorura, 1649. j Van Swieten : Comment, in Aphorismos Boerhaavii. Parisiis: T. iv, p. 122. | Desault: (Euvres Chirurgicales recueillies par Bichat. T. ii. 1798. 686 PARACENTESIS OF THE PERICARDIUM. operation, and cannot be appealed to, except as an argument to show the obscurity of the diagnosis. Larrey's ease is not more conclusive, although it has also been often appealed to.* These two cases of alleged paracentesis of the pericardium, both origi- nating in errors of diagnosis and both terminating in death, hardly advanced the question : they may be considered as leaving matters as they were. With the exception of an interesting essay in which Skielderup defends tapping the pericardium, without, however, citing cases in support of his views,f the operation was either forgotten or very severely criticized. Corvisart,£ who in the first edition of his work, which appeared in 1806, was satisfied to report Desault's case, proposed paracentesis of the pericar- dium in a subsequent edition published in 1818: he recommended an in- cision with the bistoury, as preferable to a puncture with the trocar. He stated, however, that he thought the possible advantages of the operation would rarely counterbalance the danger to which it exposed the patient. The opinion then held in Germany was similar to that of Corvisart: and Kreysig, in a work which he published in Berlin in 1816, on paracentesis of the pericardium, holds that it would be very difficult to apply the opera- tion usefully in practice. Besides, he said, the disease being of such a nature as to render tapping of little avail, there is always the fear of consec- utive inflammation of the heart with its inevitable results. The introduc- tion of air would induce suppuration leading to death. In harmony with the opinion of his contemporaries, he added, that the means of diagnosis were not sufficient to excuse the temerity of resorting to such an operation. In France, Laennec, adopting the views of Senac, thought that there might be a possibility of curing dropsy of the pericardium by a surgical operation. He only supported this opinion, however, by presumptions. Richerand went farther than Laennec, by proposing as a means of radical cure, a treatment by astringent injections similar to that pursued in dropsy of the tunica vaginalis. Such was the position of the question as one of science, when, in 1839, Schuh, one of the principal physicians of Vienna, published a remarkable work entitled : " De 1'Influence que la Percussion et 1'Auscultation sont appelees a exercer sur la Pratique Chirurgicale." He therein reviewed the services rendered by both the new means of diagnosis, and specially applied himself to show the reliability of surgical diagnosis based upon signs which were almost certainties. Pleuritic effusions, for the treatment of which he invented (as I have told you) a special apparatus, and pericardiac effusions were cited as the most convincing examples in support of his opinion; and be summed up by stating that, suitable cases presenting, he should not hesitate to perform one or other of these paracen- teses as the case might require. An opportunity soon presented itself. In the following year, paracentesis of the pericardium was practiced for the first time. The operation was performed in the wards of Professor Skoda, and Schuh was the operator. Notwithstanding the interest which attaches to the case published by Skoda, and which Dr. Lasegue and I have reported in extenso, in the paper which we contributed to the Archives Generales de Medecine, it would be occupying your time unnecessarily to repeat the details upon the present occasion; particularly, because when considered from the special point of * Larrey : Sur une Blessure du Pericarde suivie d'Hydro-pericarde. [Bulletin des Sciences Medicales: 1810.] f Skieldertjp: De Trepanatione ossis Sterni, et Apertura Pericardii. [Acta Nova Societatis Medicines Hafniensis: 1818.] J Corvisart: Maladies et Lesions Organiques du Coeur et des Gros Vaisseaux. Paris: 1806. PARACENTESIS OF THE PERICARDIUM. 687 view now engaging our attention, this first attempt at paracentesis of the pericardium was not very encouraging. In fact, upon two occasions, the attempt to make the puncture was a failure. On the first occasion, the in- strument penetrated a heterologous mass six inches thick occupying the mediastinum : this mass impinged upon and altered the sternum: the inner surface of the clavicle and upper four ribs were attached to the vertebrae, adhered strongly to the lungs, and encircled the large vessels and the wind- pipe. From this first puncture, there came only a very small quantity of sanguinolent serosity of the consistence of syrup. After prolonged and in- effectual attempts to obtain more fluid, the canula was withdrawn ; and it was resolved that a second puncture should be made in the intercostal space immediately under that first perforated. A certain quantity of reddish se- rosity was obtained by this second puncture; but the relief which the patient experienced was of short duration. Nevertheless, this case afforded valuable instruction; for it was a decisive experiment to show that para- centesis of the pericardium ought not to be looked upon as one of those bold proceedings which are hardly justified even by success. In the following year, Dr. Heger, a pupil of the learned professor of Vienna, operated in a case of dropsy of the pericardium, which though not complicated with conditions so unusual as those met with in the former case, was associated with other pathological states, which, as I shall forth- with tell you, and as Dr. Aran has shown, generally coexist with this dis- ease. Dr. Heger's case published in a German journal deserves to be reported to you. The patient was a shoemaker aged nineteen. He stated that on admis- sion to the hospital he had had the disease for about six weeks which brought him thither. He complained of dyspnoea, which at first was not alarming, but afterwards became so severe that on the 1st July, 1841, the day of his coming into the hospital, suffocation seemed imminent. On admission, his countenance was anxious, pale, and somewhat oedema- tous : respiration was short, quick, painful, and panting. The patient kept in a half-sitting position. When he tried to turn on the left side, he felt an acute pain accompanied by great dyspnoea. The expectoration consisted of a thick yellowish mucus. There was found complete dulness on per- cussing over the whole of the sternum from its right margin to the anterior portion of the left side of the chest, from the second rib to the epigastric region, and laterally from the left margin of the sternum for six inches. Below the left clavicle, along the scapula, and in the axilla, the sound was clear; behind, on the same side, it was tympanitic. The whole of the front of the chest was clear on the right side to the sixth rib: from the fourth rib laterally, the sound was obscure. Behind, there was dulness increasing from above downwards: on the left side, there was tympanitic resonance. The liver was prominent and descended two finger-breadths into the hypo- chondrium. There was arching of the precordial region. The impulse of the heart was imperceptible, and its sounds were very obscure. In the inferior sternal region, a friction-sound was heard which it was difficult to distinguish amidst the noise of the mucous rattles. On the right side, below and in front, large mucous rales were audible, while behind, no respiratory sound could be heard. The patient had some appetite for food; and had almost no thirst. The heat of the skiu was normal. The pulse was small, irregular, and 112. There was neither diarrhoea nor constipation. The urine was of a deep red color. The patient complained of a feeling of pressure over the epi- 688 PARACENTESIS OF THE PERICARDIUM. gastrium, and of pains in the precordial regions, when he leaned against the left side. The diagnosis was: extensive effusion into the pericardium, consequent upon an attack of pericarditis, compressing the lower part of the left lung, slight effusion into the right pleura, accompanied by infiltration of the pul- monary parenchyma, following pleuropneumonia and general bronchial catarrh. Some relief was afforded by very active measures employed to promote absorption of the fluid : the pulse became less irregular. Percussion showed that the infiltration of the inferior lobe of the right lung was less, but that there was no diminution in the effusion into the pericardium. The patient was losing flesh. Mercurial preparations, from which most excellent results had been obtained,were uselessly pushed to larger doses, without producing diarrhoea or salivation. On the 3d August, three months after the date of this man's admission to hospital, incipient ascites was detected. It wTas then resolved to perform paracentesis of the pericardium; and, on the following day, Dr. Heger operated. The place selected for the puncture was in the fifth intercostal space, and at a point about two inches from the left margin of the sternum, where the friction-sound was not heard, and where there was less risk of wounding the internal mammary artery and large vessels. In the first in- stance there flowed about twelve grammes of reddish serosity. Unsuccess- ful attempts were made to render the flow continuous by using in the first instance a catheter, and then a suction-pump: a freer discharge, however, was obtained by getting the patient to hold in his breath and make an ex- pulsive effort, strong pressure being made at the same time over the epigas- trium. The fluid only came in jets under the influence of the systole. The serosity obtained was brownish-red: at first it was clear, and then it was flaky : in quantity it was above 1500 grammes. During the operation the pulse was 112 and small. At intervals the friction of the heart upon the canula was heard. Not one bubble of air penetrated into the pericardium. Almost immediately after the paracentesis marked relief was experienced. The diaphragm regained its natural position, and the arching of the chest became less : the sound was clearer in the second intercostal space and along the outer margin of the scapula: the friction-sound had disappeard. The extent of the dulness, however, led to the conclusion that there existed from seven hundred to eight hundred grammes of fluid within the pericardium. The wound was covered with a piece of diachylon plaster; and compresses soaked in iced water were placed on the side, to prevent the reaction being excessive. At 3 p.m. the patient had a shivering fit, and increased rapidity of breath- ing, but no cough. The pulse was 104. He passed a restless night, had some cough, and slight pain in the wound. Next day there was observed short rapid breathing, fits of coughing, mucous expectoration, a pulse of 112, constipation, dulness in the lower third of the left side of the chest, numerous subcrepitant rales, and a fric- tion-sound at the bottom of the sternum. With a view to check the pneu- monia in the left lung the patient was bled: the blood was very buffy. Till August 10th the pericardiac effusion wTent on increasing: the sound on percussion had again became dull in the second intercostal space: the friction-sound was no longer audible: the sounds of the heart were more obscure : there was an increase in the intensity of the fever: the loss of flesh was becoming a greater cause of anxiety: and it was feared that there was a development of tubercle. During the following week there was an amelioration in the general PARACENTESIS OF THE PERICARDIUM. 689 state of the patient: the pneumonia of the left side was undergoing resolu- tion, but there was effusion into the pleura of the same side. On the 17th there was diminution of the effusion on the right, and in- crease of the effusion on the left side. The pulse, which was small and irregular, ranged between 120 and 124. There was oedema of both malleoli and of the left leg. The dyspnoea was increasing and becoming complicated with excitement. Four days later this oedema had become very great; and the local condition of the patient was the same as on his admission to hos- pital, but the cachexia was much more threatening. On the 22d the pericardium was punctured: the result was the flow in drops of deep red fluid: every effort failed to render the flow continuous. The patient, with the canula in situ, lay on the edge of the bed for fully two hours, so that the serosity might be collected. In all there was hardly obtained 400 grammes of a turbid bluish-red fluid. For the canula there was then substituted a caoutchouc tube firmly fixed, and closed at its free extremity by a movable valve of pig's bladder. The liquid continued to flow through this tube from eleven in the forenoon to three in the afternoon; and the quantity may approximately be estimated at 500 grammes. The dulness continued after the puncture, but the movements and sounds' of the heart became more distinct. The patient, exhausted by the long time occupied by the operation, experienced no relief from it. The pulse was 116. At five in the evening the patient had a shivering fit. The tube was then removed, when there was again detected a pneumonia of the left side with bronchophony, bellows-sound, rales, and characteristic sputa. Forty- eight hours later this pneumonia passed into the stage of resolution, but the respiration still remained harsh. On the 29th, there was a notable diminution in the amount of effusion : and there was a gradual progress in its absorption up to the 1st September. At that date, the pericardial friction-sound, which had returned, had ceased. The sound on percussion was almost normal up to the left nipple, and in the axilla: it was perfectly clear anteriorly in the first two intercostal spaces. The amount of oedema was insignificant: the cough was moderate, and the respiration was nearly natural: still, the patient continued to lose flesh. On the 4th September, there were diarrhoea, oedema of the lower extrem- ities and face, particularly on the left side. The sound on percussion on the upper and front part of the same side of the chest had again become tympanitic. On the 11th, the left pleural effusion had made very great progress. There was complete dulness as high up as the axilla. Behind, there was enormous bronchial respiration; in front, respiration was harsh and whis- tling. It was impossible to measure with precision the extent of the peri- cardiac effusion. There was general anasarca up to within half an inch of the umbilicus, and there was ascites. The dyspnoea was extreme: the skin was cold and livid ; asphyxia was becoming more and more threatening ; and the pulse was too rapid to be counted. These symptoms increased in severity, and next day the patient sunk under them. At the autopsy, the left lung was found free in the thoracic cavity, and the right was fixed by strong cellulo-fibrous adhesions. The left pleura contained from eight to nine pounds [pints], and the right five pounds of brownish serosity. The right lung, pushed back along the spinal column, was slightly compressed; its inferior lobe was dry and bluish, and the su- perior lobe was infiltrated with serosity, which was partly frothy and partly unmixed with air. The left lung, also pushed back and compressed, had undergone similar changes, with this exception, that there was a tuberculous cavity surrounded by a deposit of crude tubercle. The pericardium adhered vol. i.-44 690 PARACENTESIS OF THE PERICARDIUM. to the ribs by its anterior surface from the second to the sixth rib. There were tuberculous glands in the anterior mediastinum. The pericardium was several lines in thickness; it adhered to the heart throughout the greater part of its anterior and posterior surface, and contained several ounces of yellowish flocculent fluid. By careful examination three layers of deposit on the pericardium could be distinguished; and the middle layer had un- dergone tuberculous degeneration. The heart was large and flaccid. Its dilated ventricles contained a black, soft coagulum. There was an ascitic effusion. The liver was of a brownish color, and hypertrophied. Gentlemen, the remarkable feature in this case is the pleural and peri- cardiac effusions progressing almost simultaneously: this happened also in the young man in whom I was obliged to perform in succession paracentesis of the chest and of the pericardium. The pericarditis developed itself slowly, almost without any acute stage, and without any violent inflammatory symp- toms at the beginning of the attack. To make up for the absence of acute symptoms, there was extensive effusion, as in dropsy of the pericardium and in hydrothorax. Chronic oedema of the lung, anasarca limited at first to the lower extremities, and ascitic effusion, are almost necessary consequences of disturbance of the circulation; and therefore, in this case, we have no ground for being surprised either at their occurrence or duration. I have intentionally dwelt upon the symptoms of tuberculization existing during life, and upon the lesions characteristic of that condition being found after death. These, in fact, are the complications to which I for- merly alluded, when I said that they were generally coincident with dropsy of the pericardium. You recollect, that in my lectures on hydrothorax, I pointed out to you that extensive pleuritic effusions of a chronic and latent character are frequently manifestations of the tuberculous diathesis, in this sense, that they affect individuals who, although they have not as yet any sign of tuberculization, ultimately succumb to a tuberculous affection, which may or may not be an affection of the respiratory organs. In relation to this point I cited the case of the son of my colleague, Dr. Thillaye, who died of tuberculous meningitis some months after having been successfully treated by paracentesis of the chest for extensive pleuritic effusion. Well then, gentlemen, it appears that a similar rule applies to dropsy of the pericardium. This, at least, was an opinion expressed by my lamented colleague, Dr. Aran. His personal experience, and attentive study of cases published by others, led my accomplished colleague to conclude that dropsy of the pericardium, when chronic and latent, generally coexists with tuber- culous disease, and that these pericardiac effusions, which may be called symptomatic, are also generally those which assume such proportions as to necessitate paracentesis. To conclude this historical review of paracentesis of the pericardium, let me remind you that Dr. Merat mentions two successful cases of Dr. Remero of Barcelona ;* and let me also quote from memory the practice of Dr. Bowditch of Boston, who, in desperate cases, has also performed this opera- tion with success. I would also add, that in a discussion which arose in the Sociefe de Mddecine des Hopitaux de Paris in relation to a case brought forward by Dr. Behier, it was stated by Dr. Henri Roger that during his visit to Germany he had seen Professor Skoda puncture the pericardium without a successful result. Gentlemen, Dr. Aran had twice occasion to perform this operation. On a previous occasion, at the end of 1853 or beginning of 1854, prior to my operation upon the second patient to whom I referred at the commence- * Dictionnaire des Sciences Medicales. PARACENTESIS OF THE PERICARDIUM. 691 ment of this lecture, he attempted the operation, but had not the courage to complete it. After carrying an incision through the thoracic walls, and reaching the pericardium, he stopped short. When he felt the heart beat- ing immediately under his finger, carried deep into the wound made by the bistoury, he was afraid to touch it, and so renounced the operation. Who can blame the physician for showing such an excess of prudence under the circumstances? The operation had only in rare cases been brought to the test of experience; and the operations performed in France were but little encouraging. Notwithstanding the comparative certainty which has in our day been attained in the diagnosis of effusion into the pericardium, the diagnosis is still sufficiently difficult to leave room for the physician being deceived ; and the special form of the dulness in peri- carditis, very different from the rounded dulness due to hypertrophy of the heart, is a very uncertain sign. May it not be well to carry in the mind a case which, among many others, is well calculated to show that even with men the most able, errors are sometimes inevitable ? Jn 1841 or 1842, Dr. Vigla, now physician to the Hotel-Dieu, when doing duty for Professor Rostan, found a young man in his wards suffering from dyspnoea approaching to asphyxia. He was unable to give any account of himself; and all that was known of him was that he had come out of the Hopital du Midi. Over the precordial region, he bore the cica- trices of recent cupping. His general appearance and physiognomy indi- cated that he had recently had an illness. On examining this young man as minutely as the circumstances per- mitted, Dr. Vigla found that the lungs were free from appreciable lesions ; but that in the region of the heart, there was extensive dulness, with absence of normal or abnormal sounds; the pulse was very small and rapid. All who saw the patient concurred in diagnosing great effusion into the pericardium, recent in its origin, and the result of inflammation. Certain death being imminent, prompt and decisive action was impera- tive. Under the circumstances, paracentesis seemed the only proceeding which fulfilled the indication ; and Roux was asked to perform that opera- tion. Roux proceeded with extreme caution, and made the opening by incision in preference to puncture: the result testified to his sagacity in so acting. When he reached the pericardium, and introduced his finger into the wound, he felt the heart beating, and recognized a slight friction between it and the pericardium, without, however, detecting the slightest degree of fluctuation. The operation was suspended, and inevitable death was expected. The patient, without having inhaled ether or chloroform-the properties of which were not then known-was almost unconscious of what was done to him, and quietly sunk from asphyxia. At the autopsy, there was found dilatation, which was quite a phenomenon [dilatation phenomenale] to use Dr. Vigla's expression, with attenuation of the walls of the heart: there were no valvular lesions, and no serosity in the pericardium. The following case, which occurred under your own observation, corrobo- rates still farther the point which I at present wish to establish : A young woman, in November, 1862, came into my wards in the Hotel-Dieu and occupied bed 12 of St. Bernard's Ward. She had been recently confined of her fourth child. She complained of breathing with difficulty. The symp- toms were dyspnoea, pale countenance, blue lips, anxious expression, oedema of the inferior extremities, and a small though regular pulse. The extent of the dulness in the precordial region, and the acute pain experienced when that region was percussed, testified to the existence of heart disease. 692 PARACENTESIS OF THE PERICARDIUM. This young woman had been suffering for a long time from palpitation of the heart, and the slightest exertion brought on difficulty of breathing. She stated that she had had several attacks of acute articular rheumatism. The cardiac affection was of a complex character. The great extent of the precordial dulness, the sounds of the heart seeming muffled, and as if dis- tant, there being moreover a rasping bellows-murmur accompanying the first sound, heard at the base of the heart, and extending into the vessels of the neck, and the smallness of the pulse, justified me in concluding that there was serous effilsion into the pericardium, and contraction of the aortic orifice. Dr. Barth, who examined the patient at my request, concurred in my diagnosis: he also thought, that perhaps there were clots in the heart. In addition to the cardiac disease, we found the signs of general bronchitis, and slight effusion into the left pleura. Ought paracentesis of the peri- cardium to be performed? I hesitated. Next day, there was less oppres- sion of the breathing, a diminution in the extent of the dulness, and less pain on percussion. After the lapse of some days, the pleuritic effusion was to a great extent absorbed, and by degrees the amelioration in the general state of the patient became so great that in opposition to my advice she left the hospital at the beginning of December, that is to say, in rather less than a month after admission. After eight days' absence, however, she returned to the Hotel-Dieu. Consequent upon slight fatigue, her difficulty of breathing had returned in an aggravated degree: her pulse was small and irregular, and although there was still great cardiac dulness, the bellows-murmur at the base, ac- companying the first sound of the heart, appeared more superficial: the dyspnoea soon increased, and the oedema of the inferior extremities also made progress: the pulse could not be felt in the radial arteries, and was hardly appreciable in the carotids: the extremities were cold. The op- pression became greater and greater; and after a continuance for two days of symptoms of immediately impending death, the patient expired in a faint. At the autopsy, the appearances found demonstrated that pericarditis had existed : false membranes of recent formation were found floating in a small quantity of serosity. There was great hypertrophy of the heart; and this was of itself sufficient to explain the extent of the precordial dul- ness. The aortic orifice was so contracted by calcareous deposits as hardly to allow the passage of a goosequill. The left pleura contained a small quantity of effusion, and some cellular false membranes. Both lungs were oidematous in their posterior and inferior parts : the bronchi were gorged with mucus, but the bronchial mucous membrane did not present any traces of recent inflammation. The important point to remark in this case is that the effusion into the pericardium was never so great as had been supposed; for the extent of the precordial dulness nearly corresponded to the enormous hypertrophy of the heart. The feebleness and seemingly distant sound of the pulsations of the heart resulted from the feeble contractions of that organ, and not from a thick layer of serosity being interposed between the heart and the walls of the chest. The two cases which I have just related prove then, that we cannot always affirm that the pericardium contains a large quantity of effusion, even when the majority of the signs of effusion are present; and conse- quently, it is always necessary to proceed with extreme caution in perform- ing the manual operation,, when it is supposed that paracentesis is indicated. Dr. Aran's patient died from asphyxia, occasioned by dropsy of the pericardium.. On opening the body after death, there was found the effu- PARACENTESIS OF THE PERICARDIUM. 693 sion diagnosed during life-effusion sufficient in quantity to obviate the fear of wounding the heart when making the opening into the pericardium ; and the only concomitant lesions were some tuberculous granulations on the pleura. The operation evidently offered great chances of success in such a case; and Aran was resolved not to let the opportunity slip should a simi- lar case present itself. He did not require to wait long. On the 6th November, 1855, my lamented colleague read to the Academy of Medicine " a case of pericarditis with effusion treated successfully by tapping and iodinous injections." I shall now read this case to you in the form in which it was published at the time.* , " The patient was a smelter of metals, a young man of twenty-three or twenty-four years of age. Though of a miserably delicate constitution, he had never suffered from serious illness, except when he was for a month in my wards, at the close of 1854, for a pleurisy of the left side with exten- sive effusion. He left the Hopital Saint-Antoine in fair health on the 21st of last November. A month afterwards, he perceived a pain in the chest, near the third or fourth rib, accompanied, when at his work, by a little difficulty of breathing and some palpitation of the heart. The pain con- tinued till the fine season set in, but with the warm weather it disappeared. This young man was consequently in very good health, when towards the middle of last July, he was seized with fever, cephalalgia, shivering, pains in the back, decided pain under the left nipple, palpitation, and dyspnoea. "On the 27th July, the date at which he came into my wards, there could be no doubt of the existence of pericarditis with extensive effusion. On the one hand, the patient had high fever, marked by intense heat of skin, cephalalgia, urgent thirst, and a pulse of 116 : on the other hand, the local signs were more characteristic-there were lancinating pains in the fourth and fifth intercostal spaces on the left side, in front, which were increased by pressure: there was also very great sensitiveness over the epi- gastrium, when pressure was made with the hand: there was greatly increased precordial dulness commencing superiorly below the third rib, and extending inwards to the right synchondrosternal line, measuring 12 centimetres vertically, and 14 centimetres transversely: the impulse of the heart was almost imperceptible, and its sounds seemed as if muffled and distant. " The wretched constitution of this patient, and probably old date of the beginning of the heart disease, did not encourage me to subject him to a very energetic antiphlogistic treatment. Moreover, for eight days he had had looseness of the bowels, and a state of chest somewhat doubtful, there being on the left side in particular, diffused sibilant rales : this condi- tion still less induced me to resort to large bleedings. On the first day, therefore, I took blood by six cupping-glasses, administered calomel inter- nally in small doses ; and with a view to induce rapid salivation, I ordered the front of the chest to be rubbed three times a day with mercurial oint- ment. "This treatment was not in any degree successful. I tried in vain to assist it by applying in succession two large flying blisters to the precordial region. Not only were the symptoms not arrested, but the effusion increased day by day, and with this, the impediment to respiration and circulation became augmented. Before three days had elapsed, the pulse had become feeble, irregular, unequal, and very rapid. I persevered in the administration of mercurials, but had great difficulty in even slightly affecting the gums. "As the character of the pulse was becoming more and more indicative * Bulletin de 1'Academie de Medecine, t. xxi, p. 142. 694 PARACENTESIS OF THE PERICARDIUM. of an impending aggravation of the symptoms, I soon found that it was im- perative to take action. On the 7th of August last, at the morning visit, I was told that the previous day and night had been frightful: the patient had been almost suffocated, and had been obliged to pass the night sitting up in bed. The respirations were 40, and the pulse 120 in the minute: the pulse was irregular, intermittent, and unequal. The embarrassment of respiration and circulation were only too well explained by the local signs: there was dulness extending two centimetres beyond the right edge of the sternum, and measuring transversely from 14 to 16 centimetres, and verti- cally 12 centimetres: below this situation, the sounds of the heart were inaudible; there was an absence of impulse: the liver was pushed down- wards and to the left of the median line. " What ought to be done ? Ought the same treatment to be continued. Its inutility was certain. Ought antiphlogistic measures to be resorted to? The weak condition of the patient explicitly contraindicated such means ; and moreover, it was necessary to relieve the patient at once, or leave him to die within a few hours. I resolved to tap the pericardium." Dr. Aran selected the same mode of operating which was adopted by Professor Jobert in the case in my wards; that is to say, penetrating with a trocar through the fourth or fifth intercostal space direct into the cavity of the pericardium. "However," in continuation, says Dr. Aran, "I was not without uneasi- ness as to the result of using an ordinary trocar; and so, with a view to avoid a possible mishap, I employed a capillary trocar, such as I have suc- cessfully operated with in hydatid cysts of the liver. Thus, I found myself more at my ease, being convinced that a puncture of the heart by a capil- lary trocar could not be followed by mortal hemorrhage into the pericar- dium. But was there no way of absolutely guarding against this accident? This security I expected to obtain, by adopting the following precautions. " The circumference of the pericardium was circumscribed by a series of concentric lines of percussion proceeding towards the heart from different parts of the chest, and the shape of the surface of the dull part being thus carefully delineated, I endeavored, by the ear, to limit the zone within which the sounds of the heart were quite inaudible, that in which they were slightly heard, and that in which they were distinct. The sounds of the heart could not be heard in the lower part of the dull region, and seemed as if muffled and remote in the fourth intercostal space, to the inside of the nipple; they were absent in a space of sufficient extent to enable the opera- tor if necessary to insert the trocar from before backwards without risk of wounding the heart. For greater safety, I selected a point in the fifth intercostal space, at which I made an incision in the skin with the lancet, and then, slowly introducing the trocar from without inwards, and some- what from below upwards, after having once withdrawn the inner stylet without seeing any flow, I reached the pericardium by two stages: there immediately occurred a spurting gush of fluid, affording satisfactory proof that the sac had been penetrated. " The tapping of the pericardium was certainly accomplished within a shorter space of time than I have taken to describe the operation. Those only who can recollect the feelings with which they performed this opera- tion for the first time, can estimate my anxiety at the commencement of the proceeding, and my lively satisfaction, my extreme comfort, when I saw the evacuation of the fluid progressing. I withdrew by the trocar about 350 grammes of reddish transparent serosity. At first, it came in spurts, and afterwards it dribbled out; but the patient aided the flow by efforts PARACENTESIS OF THE PERICARDIUM. 695 which he prolonged as much as possible, in consequence of the decided relief which he experienced from the evacuation of the fluid. " The sounds on percussion corresponded with the progressive diminution of the dulness arising from the evacuation of the fluid ; and on auscultation they were heard, more and more distinctly, unaccompanied by a rubbing sound. The pulse became fuller, more regular, and less frequent; it fell from 120 to 96 in the minute. " I might have rested satisfied with having performed a single palliative tapping; but I thought I could do something more for the patient. Rely- ing upon the success I had obtained in pleurisy, I slowly injected an iodin- ous solution, composed of 50 grammes of water, 15 grammes of tincture of iodine, and 1 gramme of iodide of potassium. I did not feel very com- fortable in respect of this injection. I asked myself: what is going to happen ? I said, has it not been alleged that the pericardium is endowed with excessive sensibility? The injection, however, was not even felt. After having retained the injection in the pericardium for some moments, I al- lowed some grammes of it to escape, and then closed the wound by means of graduated compresses, and by placing a bandage round the body. " The results of this tapping were very simple, but the fluid was repro- duced, and ere long the patient lost a great part of the ground which be had gained by the operation. Respiration became more embarrassed, and the pulse irregular and more rapid. The dulness, which had at first seemed to diminish, increased, particularly in a lateral direction. There was mani- fest arching of the chest. The pulsations of the heart were deepseated. To be brief: on the 19th August, twelve days after the first tapping, I tapped a second time; and, as before, between the fifth intercostal space, following, moreover, exactly the same proceedings as on the previous occa- sion. At this second operation, I evacuated 1350 grammes of a very albuminous, greenish liquid, in color resembling bile. As on the first occa- sion, this fluid came in gushing spurts, but it afterwards dribbled out. The patient, feeling relief from the flow of the fluid, assisted me by his efforts, which it was necessary to restrain through fear of allowing air to penetrate into the pericardium : however, air did penetrate after the injection of the solution of iodine, the strength of which was now increased to fifty parts of tincture of iodine to the same quantity of distilled water, with the addition of four grammes of iodide of potassium: nearly the whole was allowed to flow out again. I was consequently enabled to detect the curious sign of hydropericarditis, for the description of which we are indebted to Dr. Briche- teau, viz., an excessive gurgling, a sort of churning sound [clapotemenf] like that produced by a pump jumbling air and water together in the same cavity. After the operation, the precordial region was the seat of well- marked tympanitic resonance. " The results of the second were not less simple than the results of the first tapping; but the relief experienced was still more marked, for some hours after the operation, the gurgling and tympanitic resonance had dis- appeared from the pericardium. On the very evening, however, of the day of the operation, the reproduction of the effusion began. Up to August 21st, the extent of the dulness seemed to be increasing; on the 22d, it re- mained stationary; and from the 23d it began to diminish, particularly below and laterally. The sounds, though feeble, soon began to be per- ceptible at the apex of the heart; and from August 28th, the dulness did not extend inwards beyond the median line, nor outwards beyond the nipple, nor superiorly beyond the third rib. ''Notwithstanding this apparently favorable progress of the disease, the young man still had other dangers to incur. The chest affection under 696 PARACENTESIS OF THE PERICARDIUM. which he was suffering at the date of his admission to hospital, was not remaining stationary; and in proportion to the degree in which the heart symptoms seemed to moderate, the signs of pulmonary tuberculization became more and more evident, particularly in the left lung, in which, at first, I had noted symptoms of inflammation. This was not all: towards the end of September, the ankles became oedematous, and some days later, the swelling invaded the scrotum, the lower extremities, as well as the thoracic and abdominal parietes. " Since the end of October, the oedema has been completely gone-thanks to his youth, and thanks also, probably, to the application of numerous flying blisters to the chest, and the use of vapor baths. There has seemed also to be a gradual amelioration in the thoracic phenomena: with return of appetite, there came return of strength: respiration regained its freedom, and with the exception of a continuance of cough at night the patient may consider himself as completely cured of an affection which had brought him to the very brink of the tomb. Need I add, that the physical signs of pul- monary tuberculization still remain, notwithstanding the amendment which has taken place in the general and local condition of the patient?" I do not feel at all afraid, gentlemen, of having trespassed on your patience by reporting at length this case so full of interest from every point of view : it is not, moreover, the only case of tapping the pericardium which Aran had to record: a short time before his death, he told me that he had thrice performed, and thrice performed successfully, this operation. These cases, other cases which have occurred in my own practice, and cases which might now probably be added, conclusively demonstrate that paracentesis of the pericardium is not beset with the perils which for so long time frightened experimenters, but existed only in their own imagina- tions. Were it not for the diagnostic difficulties presented by dropsy of the pericardium, difficulties very much more serious than those which some- times occur in the diagnosis of hydrothorax, tapping the pericardium would be as simple an operation as paracentesis of the chest or abdomen. Indeed tapping the pleura, though in most cases exempt from danger, is more calculated than tapping the pericardium to excite fears, and lead to bad consequences. Not only is paracentesis of the pericardium free from risks; but experi- ence appears likewise to have fully established the safety of using injections for the radical cure of dropsy of the pericardium. Thus, therefore, are realized the anticipations of Richerand who was the first by whom the idea was conceived of applying to effusions into the pericardium that treatment which is employed every day in cases of hydrothorax, ascites, and effusions into joints. Professor Bouillaud in his Traite Clinique des Maladies du Cceur, without venturing to give a decisive verdict on paracentesis of the chest and the value of iodinized injections, enunciated the following opinion in the second edition published in 1841: "An exaggerated notion has prob- ably been entertained of the dangers of pericarditis, a condition which must be produced before it is possible to have adhesion of the opposite surfaces of the pericardium, the sole means of preventing a reaccumulation of the fluid evacuated by the tappingand he adds that " pericarditis produced by irritant injections would be a proceeding of the simplest possible de- scription." Gentlemen, I have now a few words to say on the operation itself. Several points have been proposed as the most suitable for opening into the pericardium. As I have already told you, Senac, Skielderup, and Laennec recommended that the sternum should be trepanned immediately PARACENTESIS OF THE PERICARDIUM. 697 above the ensiform cartilage, and, with a view to fix the spot with more precision, they advised the puncture to be made below the insertion of the cartilage of the fifth rib. Larrey believed that it was easier and more convenient to make the puncture between the edge of the ensiform cartilage and the cartilage of the eighth rib on the left side. By carrying the instrument from below upwards, and a little to the right, the pericardium will be reached, he thinks, with greater safety, and in such a way as to give freer egress to the fluid. I at first looked on this method as very rational: but on recollecting that surgeons have properly called attention to the risk of encountering a branch of the internal mammary artery, which is sometimes of such a calibre as to reach to the ensiform cartilage; and reflecting also on the fact that-in accordance with a remark of Professor Velpeau-the instrument might be carried in such a direction as to avoid the pericardium in subjects whose oedematous state or plump condition was sufficiently decided to prevent the skin from coming into immediate contact with the cartilage and ensiform appendix, I renounced that method. The place which I select as the most favorable for the operation is that which M. Jobert and I chose in our own two patients,-the fourth and fifth intercostal spaces. The precautions adopted by Aran, and pointed out in his case, are useful: when an occasion occurs, you will do well to put his precepts into practice. Tapping may be performed either directly by means of the trocar, or by incising with a bistoury, layer by layer, the thoracic walls and the peri- cardium, or by adopting a mixed proceeding; that is to say, by first cutting through the superficial layers, and then puncturing the subjacent tissues by the trocar. I admit that there is something in the simplicity of the proceeding which renders it a more attractive operation to puncture with the trocar than to cut with the bistoury. But let me repeat, that the diagnosis of dropsy of the pericardium is not always so easy as is' alleged: in making a direct puncture with the trocar, I should be afraid of coming upon the heart. This is a risk which I should dread even more in a case in which there really was effusion into the pericardium, for the heart, in place of flying before the instrument, might, as has been well expressed by Senac, come up to meet it, and thereby be run through. Even when using Aran's capillary trocar, I should still be very far from being without anxiety on that score. The only inconvenience which I can see in using the bistoury, is that some of the fluid effused into the pericardium may fall into the pleura, flowing out between the edges of too large an incision, and the canula in- troduced into the pericardium. No importance attaches to this inconveni- ence : in fact, it has been shown by experiments made on wounds of the chest-a subject which I discussed with you at some length the other day- that blood effused into the pleural cavity is very rapidly absorbed ; and the same rapidity of absorption ought to take place in respect of a serous effusion. There is, therefore, no danger in allowing a fluid which is even less irri- tating than blood to fall into the pleura. Mark well this fact: if the fluid effused in a case of pleurisy is not absorbed, it is either because the pleura is still in a state of inflammation, or because its surface is coated with false membrane, and consequently in a condition unfavorable to the accomplish- ment of absorption. When there is no morbid condition of the pleura, ab- sorption goes on well, the symptoms are of a less serious character, and recovery is more likely to occur. If I were called upon to-day to puncture the pericardium, I should modify 698 PARACENTESIS OF THE PERICARDIUM. the operation in the spirit of the remarks I have now made. I should make my incision through the skin immediately external to the sternum, about the fifth, sixth, or seventh sterno-costal cartilage, selecting, as Aran recommends, the point where the dulness is greatest, and where it is most difficult to perceive the movements of the heart. I should try to penetrate between two cartilages, keeping as near as possible to the sternum. At the sternum, the cartilages touch one another; but by employing a spatula, or any such like suitable lever, I should be enabled somewhat to separate the edges of the two cartilages, and, if it were necessary, I should not hesitate to remove as much cartilage as would allow the pulp of the finger to reach the pericardium. The case reported by Dr. Vigla shows how necessary it is to be assured by digital examination that there is a sufficient distance between the heart and the point at which the pericardium is punctured. To facilitate the escape of the fluid, the most important circumstance to attend to is to allow the canula of the trocar to remain some time in the pericardium ; and it is useless to practice the different manipulations which have been recommended as calculated to accelerate the evacuation. Suction- pumps afford no assistance, and give a troublesome complication to the operative apparatus. However, the membranous valve which I employ in paracentesis of the thorax for pleuritic effusions may, without producing any inconvenience, be attached to the free extremity of the canula, although its utility is an open question. As soon as the canula has been introduced into the pericardium, the liquid begins gradually to flow out. Aran observed in his cases, that the continuous jet which the fluid formed was sometimes projected to a great distance in spurts during deep inspirations-a phenomenon which he attrib- utes to the pressure of the lung on the pericardium. This phenomenon did not present itself in my two patients, nor was it noted in the cases which I have reported to you. When the canula is removed, all that is necessary is to close the wound with a diachylon plaster kept in its place by a bandage round the body. The wound requires no treatment: it hardly occasions any pain, gives rise to no great amount of inflammation, and never leads to suppuration even of very limited extent. Gentlemen, paracentesis of the pericardium is decidedly indicated only in cases in which life is threatened by the extent of the effusion. The occasions on which it ought to be resorted to must always be of rare occur- rence. Simple idiopathic dropsy of the pericardium uncomplicated with any other dropsy, or with any serious lesion of the thoracic organs, is certainly seldom met with. Generally, profuse effusion into the pericardium is only one of the manifestations of a state of disease which is not exclusively localized in that situation, but also attacks other essential parts of the economy. I have told you that Aran enunciated an opinion to the effect that effu- sion into the pericardium sufficiently profuse to necessitate paracentesis, is generally coincident with the tuberculous diathesis. I have informed you that this opinion was based on facts observed by our lamented colleague. His own two cases, and those by the recital of which I began this lecture, completely support this view. But if we cannot hope in such cases, to cure the patient by withdrawing the fluid from the pericardium, we are at least certain of relieving suffering and prolonging life by removing a serious complication involving imminent danger. Had paracentesis of the pericardium no other reliable claim, this would entitle it to a place among operations worthy of being retained and ORGANIC AFFECTIONS OF THE HEART. 699 sanctioned. When we witness the anxiety produced by the pressure of fluid on the heart, when we witness the fearful and protracted agony resulting from such a state, we are only too happy to have it in our power to afford even temporary relief, and to be able to prolong a life which we have rendered less painful to endure. LECTURE XXXVIII. ORGANIC AFFECTIONS OF THE HEART. General Considerations.-Insufficiency of the Aortic Valves is the most serious of all the Lesions of the Cardiac Orifices.-Dropsy treated by Purgatives.- Diarrhoea sometimes requires to be arrested: at other times it constitutes a natural crisis which ought not to be interfered with.-Diagnosis of Affections of the Heart is often difficult.-Embolism and its Consequences. Gentlemen: A woman, who, on several occasions, has been a patient in our clinical wards, will afford me an opportunity of presenting some general considerations, pathological and therapeutical, in relation to some peculiar symptoms which arise in the course of organic affections of the heart-considerations which you will be able from time to time to apply at the bedsides of our patients. The woman to whom I refer latterly occupied bed 34 of St. Bernard's Ward : she came into hospital on account of complications dependent upon an affection of the heart of very easy diagnosis. Upon auscultation, the cardiac lesion was revealed by a double bellows-murmur, having its maxi- mum intensity in the situation of the apex of the heart: the blowing accompanying the first sound of the heart was harsh, and that accompany- ing the second was softer. These stethoscopic phenomena were characteristic signs of valvular insufficiency, and of contraction of the left auriculo-ven- tricular orifice. My present object is not so much to call your attention to organic lesions of the heart, as to show you the very great difficulty of making a confident prognosis; and to point out to you certain rules for the treatment of some of the complications which arise consequent upon the lesions. I would remark, however, gentlemen, in respect of valvular insufficiency, that it is generally coincident with contraction of the orifice. In fact, the causes which most commonly prevent the valves from fitting closely to one another are changes of these membranous partitions. Their thickening, their induration, their fibro-cartilaginous, osseous, or petrous transformation, their partial destruction at their free margin, their perforation, their more or less extensive rupture at the base or centre, the presence of vegetations on their surface or edges, and all kinds of structural change, which, coexist- ing with more or less considerable thickening and induration of the valves, prevent them from performing their functions in a perfect manner. This thickening and hardening, and the presence of somewhat bulky vegetations at the edges or upon the surface of the valves, irrespective of valvular in- sufficiency, necessarily narrow the orifices at the entrance of which the valves are placed. 700 ORGANIC AFFECTIONS OF THE HEART. This valvular insufficiency and contraction of the opening give rise to more or less impediment to the circulation of the blood in the heart, and this again produces a series of phenomena, some of which are local and per- tain to the heart, while others are general and belong to other organs. Some of the local phenomena are subjects of complaint by the patients. Among these are palpitation, a sense of embarrassment and weight in the precordial region or towards the pit of the stomach, which augment the muscular effort when it is necessary to exert a little more than usual, as, for example, in going up a stair. At a more advanced stage of the disease there is greater or less difficulty of breathing. These symptoms, however, are often absent. Other local phenomena, the existence of which is made out by exploration of the heart in different ways, afford us more certain diag- nostic signs of the lesion. When the disease has somewhat advanced, simple inspection of the pre- cordial region gives us some information as to the disturbance of the heart's action, and application of the hand enables us still better to appreciate it. In fact, on applying the hand, we can recognize that sort of undulatory movement, that vibratory thrill, called the purring fremitus \_fremissement cataire] which is coincident with irregularities, intermittencies, and inequali- ties of the pulsations of the heart. Auscultation by the ear, or by the aid of a stethoscope, furnish signs consisting of bellows-murmurs of great diver- sity, the physiological explanation of which has been, and still is explained by different theories, which I do not think it necessary to discuss here in detail. Let me say, however, that the beautiful experiments on horses per- formed by M. Chauveau no longer leave any room for doubt as to the cause of the normal and abnormal sounds of the heart: to those present at the experiments of which I speak, it was clearly demonstrated that Rouannet's theory is that which is alone admissible. Percussion enables us to recognize increase in the volume of the heart, whether that increase be dependent upon dilatation of the cavities or hyper- trophy of their walls. These alterations of the heart, almost invariably coincident with lesions of the orifices, are the necessary consequences of im- pediment to the circulation of the blood. The mechanism of their produc- tion is easily understood. From the moment that the muscular contractions of the heart are inadequate to overcome the obstacle to the passage of the blood out of the cavity which contains it, the walls of that cavity gradually become distended by the accumulation of blood, and in this way the cavity itself is dilated. This dilatation is seldom simple, that is to say, only the result of attenuation of the parietes: generally-almost always-the dilata- tion is accompanied by hypertrophy of the walls of the heart, originating chiefly in an excess of muscular action. Though I do not wish at present to discuss a question of general pathology, I would nevertheless call on you to observe, that there takes place in the heart a change similar to that which occurs in other hollow organs in which we see dilatation along with greater development of the muscular fibres, from the existence of an obsta- cle to the exit of the contents requiring increased efforts for the accomplish- ment of the normal expulsatory function. The same takes place in the heart, as in the bladder, the bronchial tubes, the stomach, and other por- tions of the digestive canal. This hypertrophy of the heart, as has been justly remarked by clinical observers, by Hunter, Laennec, Beau, and others, is a lesion specially and providentially employed by nature, as a means of overcoming the obstacle to the circulation of the blood. The re- sult is, the maintenance for a certain time of the performance of a function essential to life. I have stated that this lesion is to a great extent produced by an excess of muscular action; but, while I say so, I admit that we ORGANIC AFFECTIONS OF THE HEART. 701 must also take into account as a cause of the hypertrophy the pathological change in the muscular tissue, brought about by that morbid action conven- tionally termed inflammation or irritation. Let us now return to the consideration of embarrassment, more or less considerable, to the circulation of the blood in the cardiac cavities. Gentle- men, if I do not pause to study with you the precise diagnosis of the seat of the lesions of the orifices, it is because-as has been admitted by an eminent physician, whose competence to express an opinion on such a point no one will gainsay-the study is essentially one more curious than useful.* Nevertheless, the differential diagnosis of insufficiency of the aortic valves is of very great importance in practice. The most frequent causes of sudden death are those which depend upon lesions of the aortic valves; and it is likewise a fact recognized by most practitioners that these are the very lesions least frequently accompanied by that assemblage of morbid phenomena which constitute the general symptoms of diseases of the heart. Let us see what are these general phenomena. Disturbance of the functions of the heart must necessarily produce decided effects throughout the whole circulatory apparatus. Appreciable modifica- tions of the arterial pulse, of the state of the veins and capillaries, show that the circulation is embarrassed. The pulse, irregular, unequal, and intermittent, as are the pulsations of the heart, is generally small; but when there is considerable hypertrophy of the left ventricle, the pulse is also hard and vibrating, presenting sometimes a peculiar fremitus, which is most distinct in the carotid, subclavian, and radial arteries. In some cases, the arterial pulsations succeed one another stroke by stroke, and this reduplication of the pulse is coincident with a regurgitant murmur heard on auscultating the heart. The insufficiency of the aortic valves is char- acterized by a bellows-murmur at the base, accompanying the second sound of the heart, and by a bounding pulse with flexuosity of the radial artery : this last-named sign originally pointed out by Selle, and very specially insisted upon by Corrigan, is of great diagnostic value in this affection. Marey's sphygmograph gives a good representation of the peculiar char- acteristics of the pulse in aortic valvular insufficiency. You are aware that this ingenious instrument, by means of a pen attached to the arm of a lever resting by one end on an artery, each pulsation of which raises it up, delineates the arterial pulsations upon a strip of paper which goes on unrolling. Well then! Corrigan's special bounding of the pulse, which strikes the finger smartly like a trigger, is expressed on the slip of paper of the sphygmograph by an ascending vertical line terminating in a sharp point or in a sort of hook, after which comes an oblique descending line more or less flexuous in the middle. The entire tracing consists in a series of vertical and oblique lines joined by the point or hook. The height of the vertical line is in proportion to the force of the arterial diastole. But in the pulse of contraction of the aortic orifice, the ascending line of the tracing, corresponding to the arterial diastole, is not vertical, but oblique ; and the descending line is oblique in an inverse direction, and flexuous. The ascending line never attains that height which it reaches in the pulse of aortic valvular insufficiency. In insufficiency of the mitral valve, the pulse is almost always irregular, * Professor Bouillaud, in his " Traite Clinique des Maladies du Coeur " (2d edition, vol. ii, p. 362), says : " Do distinctive signs exist by which we can ascertain the precise seat of contraction in one or other of the cavities of the heart? The solution of this problem, which is essentially more curious than useful (qui est au fond plus curieux qu'utile), shall now engage our attention for a few minutes." 702 ORGANIC AFFECTIONS OF THE HEART. and of an irregularity which is absolute, and in no respect typical; that is to say, it is not represented in any uniform manner upon the sphygmo- graphic tracing. The pulse has less volume : and so feeble are some beats that it is almost impossible to appreciate them by the finger. On the trac- ing, the arterial diastole is figured by vertical lines of unequal height, and the systole by oblique tremulous lines of the most irregular form. In contraction of the mitral orifice, the pulse is regular, and the sphygmo- graphic tracing greatly approximates to the normal. In the cases in which there is a presystolic bellows-murmur, the nature of the lesion may be diag- nosed by the negative characters of the pulse.* When disease of the heart has reached a pretty advanced stage, the existing impediment to the venous circulation is indicated by swelling of the veins near the heart-those for example of the neck and face ; and this turgescence is particularly obvious in the external jugular veins, where it is sometimes accompanied by undulatory pulsations, analogous to and syn- chronous with the arterial pulse. This is the " venous pulse," which Lan- cisi (who seems to have been the first to observe) gave as the sign of hyper- trophy of the right ventricle. It is caused by reflux into the veins of a certain portion of the sanguineous tide which the right auricle has been unable to send into the ventricle: it is thus caused, whether there be con- traction of the auriculo-ventricular orifice, whether there be insufficiency of the tricuspid valve permitting the blood in the ventricle partly to regurgi- tate into the auricle, or finally, whether, by reason of the obstacles which the blood encounters in passing from the right into the left cavities, the ventricle is unable to empty itself completely. In addition to the embarrassment of the venous, there is embarrassment of the capillary circulation, which declares itself by a livid tint of the skin, swelling of the face, puffiness of the eyelids, a bluish color of the lips, and more or less injection of the skin of the extremities. The morbid functional phenomena which occur are dependent upon dis- turbance in the capillary circulation. The embarrassed respiration, at first consisting in some breathlessness after rather violent exercise, such as walking more rapidly than usual, increases in proportion as the affection of the heart makes progress, and at last reaches a high degree of dyspnoea : the disturbance of the cerebral functions, which supervenes in the last stage of the disease-the sanguineous congestion which occurs in the principal viscera, the lungs, liver, spleen, and encephalon, and which sometimes pro- ceeds to the extent of hemorrhage (pneumohemorrhage, for example, a fre- quent complication of heart diseases), or induces structural changes such as cirrhosis of the liverf-and finally, dropsical affections such as oedema of the extremities, anasarca, effusion into the serous cavities: all these phenom- ena are chiefly consequences of mechanical obstruction of the circulation. I say chiefly the result of mechanical obstruction, because mechanical obstruction is not sufficient of itself to explain the production of the morbid phenomena of which I am now speaking. • So true is this, that we some- times see individuals rapidly succumb after having presented all the general and rational symptoms of cardiac disease, and yet in whom it was never possible during life to recognize well-marked local signs of such an affec- tion, and in the post-mortem examination of whose bodies there were not found any lesions of the heart sufficient to explain either the symptoms observed or the death ; and we likewise see persons presenting all the phys- * See Marky's work entitled: " Physiologie Medicale de la Circulation du Sang." Paris, 1863. j- See a subsequent lecture on Cirrhosis. ORGANIC AFFECTIONS OF THE HEART. 703 ical signs of a disease of the heart live for a long time without appearing to experience any notable derangement in their health. If we only take into account the anatomical lesion, an organic affection of the heart is in reality not a disease. Should any one be astonished at this assertion, let me ask him if he would regard as a disease, slow progres- sive asphyxia induced by passing a noose round a man's neck and daily tightening the cord to so slight an extent that it would take two years to cause death? Organic affections of the heart, however, are always, or nearly always, more than a simple mechanical obstruction to the central circulation : the localized morbid affection, which has occasioned the forma- tion of the material obstacles, is also to a great extent the cause of all the organic and functional disorders which arise. This, truly the most medical point of view from which to consider dis- eases of the heart, is that adopted by many clinical physicians: it has recently been admirably expressed by Dr. Mauriac in his excellent thesis, from which, with your permission, I shall read some passages.* "When," says Dr. Mauriac, "we have to estimate in a general manner the causes of death in persons affected with diseases of the heart, it is indis- pensable, if one wishes fully to grasp the problem, and to look at the ques- tion in a manner at once philosophical and medical, to examine in the first place the share which certain diatheses have in the production of the sec- ondary phenomena of these diseases, when, after a period of longer or shorter duration, they throw the economy into a peculiar state of cachexia, which is conventionally designated cardiac cachexia. It is known that this special cachexia is the source of profound modifications in the crasis of the humors; and that the two principal phenomena are an asthenic condition of the cir- culation in all the splanchnic viscera, whence result passive congestions of these organs, and an abnormal exhalation of serosity into the cellular tis- sue and serous cavities. These signs of general disturbance of the system show themselves sometimes at so early a period, at a period so close to the first manifestation of the local symptoms of heart disease, that it becomes a question whether the disease, regarded as a whole, is primarily local or general. Where does it begin? Is its origin in the heart alone? Is it from the heart that there comes that morbid impulse the evolution of which will soon involve the entire economy ? Or must we seek for its origin in all parts of the circulatory system ? Or again, is the entire circulatory apparatus simultaneously affected ; and is it not the heart which is chiefly affected, because in its central action is comprised, so to speak, all the forces which put in motion that fluid which pervades and nourishes all our tis- sues ? These are great questions in general pathology to which it is not easy to reply. " It is now an accepted scientific fact, verified by every day's experience, and placed beyond dispute by the beautiful researches of Dr. Bouillaud, that there is a primary diathesic cause for nearly all diseases of the heart. It matters little, whether this general morbid state, which concentrates its energy on the organs of circulation is purely inflammatory or essentially rheumatic or gouty ; but it is important to remember that every diathesis causes every molecule to live a life specially morbid, and consequently ex- ercises upon the entire economy a profoundly debilitating influence. If every diathesis weakens the force of the organism by modifying the physio- logical performance of elementary nutrition, may not the various diatheses which originate diseases of the heart do this much more certainly by attack- * Mauriac: Essai sur Les Maladies du Coeur. De la Mort Subite dans 1'Insuffi- sance des Valvules Sigmoides de 1'Aorte. [7%£se de Paris, I860.] 704 ORGANIC AFFECTIONS OF THE HEART. ing the apparatus which conveys to all parts of the body the fluid whence assimilation derives the materials by which the tissues are nourished? Herein lies, does it not, the primary cause of that general morbid deteriora- tion of which we have to take account? " This is not all: the pathological processes peculiar to each diathesis, and from which it derives its characteristic physiognomy, disorganize the cardiac tissue, and so begins a series of secondary phenomena, which have been too exclusively ascribed to the existence of impediments to the circu- lation of the blood in the cavities of the heart. Some pathologists have even gone further than this in localizing the causes of the morbid phe- nomena ; they have ascribed these impediments to the circulation solely to the material obstacles situated at the orifices. The lesions of the orifices- contractions or inadequacies-only express one of the phases of the patho- logical changes of which the heart is the theatre: the danger which they occasion is only relative." Dr. Mauriac supports these propositions by cases, such as I have just been pointing out to you, of persons who, though they have the physical signs of apparently serious disease of the heart, live for a very long time, and more- over without presenting the symptoms of general disturbance of the economy apparently imminent from the certainty that there existed an obstacle to the passage of the blood through the heart. He then thus continues : " The doctrine regarding diseases of the heart which is exclusively based upon considerations referring to material obstacles to the passage of the blood does not solve every difficulty nor remove every doubt. The attrac- tiveness of the doctrine arises from its simplifying the phenomena by making them subordinate to a mechanical cause which the mind can appreciate much better than a vital or diathesic cause. But the operations of nature are essentially complex: a pathological phenomenon which at first sight seems to be simplicity itself, implies a change, permanent or temporary, in so many elements, or an exaltation of so many organic functions, that there is a great risk of only seeing one side of the truth, and leaving the others in the shade, if we found a theory solely on one class of phenomena." In reality, a practical fact is dominant in the pathology of the heart: the diseases of this organ are those which most deceive the physician at the bedside of the patient: their diagnosis is simple, but it is quite otherwise in respect of their prognosis. The course of the disease, and its possible com- plications, are subordinate to very many circumstances, some of which- such as the intercurrent affections-are recognizable, but the majority of which elude recognition. Speaking in a general way, it may be said, that a predisposition to pul- monary affections, that an exaggerated susceptibility of the nervous system, place those suffering from diseases of the heart in an untoward position in consequence of the manner in which pulmonary and nervous affections react on the central organ of the circulation. The former tend to occasion stasis of the blood in the right side of the heart, and consecutively in the entire venous and capillary system, thereby leading to passive congestions and serous effusions: the second are direct causes of functional disorders which greatly complicate the organic disease. But leaving generalities, I ask: who can explain why a particular individual, with the exception of the morbid conditions of which I have been speaking, may go on for a long time without experiencing much derangement of health notwithstanding an extensive cardiac lesion, while another person sinks rapidly under an or- ganic disease of the heart, the local symptoms of which were much less serious, their seat in other respects being the same ? I make this latter dis- tinction, because, as I have already said, the insufficiency of the sigmoid ORGANIC AFFECTIONS OF THE HEART. 705 valves of the aorta is of all cardiac organic affections the most serious, as 'well as one of the most frequent causes of sudden death, although it is the least frequently attended by general symptoms during life. Gentlemen, let us now resume consideration of the cases at present under our observation: let us return to the patient occupying bed 34 in St. Ber- nard's Ward. This woman was admitted four or five months ago, suffering from exten- sive anasarca. Besides infiltration of the cellular tissue of the lower ex- tremities, and puffiness of the face, she had pulmonary oedema, which, on auscultation, was found to be characterized by sibilant and subcrepitant rales, heard principally at the base of the lung. So greatly was respiration embarrassed, that death from asphyxia seemed likely to occur within forty- eight hours. The affection of the heart, however, judging from the analysis of the symptoms which I was enabled to make (though with difficulty in consequence of the greatly embarrassed state of the respiration and circu- lation) was not more serious than it is to-day. It was not the first occa- sion on which the patient had had symptoms similar to those which I was then called upon to relieve. Under the circumstances, all that I could do was to attack the general dropsy, under the impression that by promoting the evacuation of the infiltrated fluid, by freeing the blood from its excess of serum, I should re-establish the equilibrium of the circulation, and facili- tate the working of the pulmonary apparatus. Drastic purgatives-purgatives which quickly produce copious serous evacuations, and have for that reason been termed hydragogues-best fulfil this urgent indication. I therefore gave the compound tincture of jalap with forty grammes of hollands. Under the influence of the first brisk purging, the anasarca was sensibly diminished on the following day. At' my second visit, I repeated the same prescription, and obtained from it a still more decided effect. The hollands was administered some days later in the same manner: before two weeks had elapsed, the dropsy had com- pletely disappeared, and there was no longer any difficulty in breathing. I was then enabled to verify much more easily than I could at the date of the patient's admission, the physical and local signs of her cardiac affection. Under the influence of a class of remedies which the old physicians called panchymagogues, that is, remedies which purge offending humors from the blood, within from forty-eight to seventy-two hours, I got rid of the exten- sive anasarca which had occasioned such formidable symptoms. I averted imminent death, which was the sole result which the nature of the case allowed me to aspire to accomplish; for unfortunately, I could do nothing to cure the organic lesion, the basis of the disease. Having realized this terrible fact, I went on giving the diuretic wine of the Hotel-Dieu, and, after a time, bitters. Of all the hydragogue remedies which I have ever employed, the most powerful is that known as the "vin diuretique de V Hotel-Dieu," the formula for preparing which I devised, and which is as follows: Take of- White wine, . . . . . 750 grammes. Squill bulbs, ..... 5 " Juniper berries, ..... 50 " Foxglove leaves, .... 10 " Macerate them together for four days. Then add of- Acetate of potash, .... 15 " Filter. vol. i.-45 706 ORGANIC AFFECTIONS OF THE HEART. This wine, which I have employed for many years, and which has been accepted by my colleagues according to my formula which I have now given you, is generally borne well by patients: to it, both in my hospital and private practice, I owe apparent recoveries from affections complicating diseases of the heart--complications for the relief of which there seemed nothing to be done. Freed from danger for the time being, the patient soon found herself sufficiently well to ask for her dismissal from the Hotel-Dieu: the only discomfort which remained was some shortness of breath, an inevitable con- sequence of her disease of the heart. In about six weeks, she came back in a condition exactly similar to that in which she was when first received into the hospital. This relapse alarmed me all the more that I too well knew that such complications are liable to return, and must ultimately be beyond the re- sources of art: a time will come, when-if I may so express myself-the cup being already full to the brim, a single drop will cause it to overflow; in short, I knew that this woman was doomed within a short period to sink under her disease, and that she would probably be carried off by the symp- toms which affected the general economy. The success of my treatment had, however, been so conspicuous on the first occasion as to constrain me to resort to it a second time. I again employed the same means ; and on the third day, the anasarca had again disappeared, and the breathlessness had again ceased. The patient asked for food, and complained that she had too little to eat; but from the occurrence of a new complication I was prevented from satisfying her appetite. The diarrhoea produced by the tincture of jalap and diuretic wine con- tinued. That, however, did not give me any anxiety, as I thought that the flux which I had produced with a view to remove the dropsy would also prevent its return. The event was not in accordance with these antici- pations, for although the diarrhoea continued, the anasarca steadily in- creased, till it was as great as when the patient came into hospital. It was no longer possible to recur to the treatment which had been so marvellously successful on two previous occasions, for the administration of drastics and diuretics would have necessarily increased the irritation of the digestive canal, and augmented the disorders of the nutritive function upon which evidently depended the third appearance of the dropsical symptoms. Clearly, the first indication was to modify the pathological .state of the in- testinal canal: that indication having been fulfilled, there would be ground to hope that the dropsy might be advantageously dealt with by acting on the kidneys or skin, the secretion from which organs might come in the place of that from the intestinal canal. Subnitrate of bismuth and prepared chalk were first given separately, and then in conjunction, but without any beneficial result. Nitrate of silver given by itself to the extent of 10 centigrammes in the course of the day, in 10 pills, and the nitrate of silver in combination with opium, suc- ceeded no better. The diarrhoea, in place of becoming less, became more profuse. I then employed hydrargyrum cum creta (mercury killed in chalk) a preparation taken from the English Pharmacopoeia, where it is called "gray powder:" while, like calomel, this preparation is a purgative, it is also, like it, when administered in a particular manner, an excellent alterative, a modifier of the state of the intestinal canal, very useful in certain kinds of diarrhoea. The patient took ten centigrammes (about two grains) of gray powder on the first day; and from that day the intestinal flux moderated. Next day, I added three drops of laudanum to my pre- scription, ordering them to be taken immediately after the gray powder. ORGANIC AFFECTIONS 'OF THE HEART. 707 Under the influence of this medication, the number of stools in the twenty- four hours decreased from seven or eight to two. This beneficial result was obtained, but the dropsy continued : as it was no longer possible to excite the intestinal, I calculated on the renal secre- tion. As, however, the substances which act on the kidneys are apt to irritate the intestines, I was afraid that if I administered them internally, I might overturn the therapeutic platform which had cost me so much trouble to erect. I consequently resolved to apply diuretics externally, a practice of which I have had experience during the last twenty years, and which, during that period, has often rendered me signal services. I cause a strong decoction to be made of squill bulbs and digitalis leaves; or, I take from 100 to 150 grammes of squills and the same quantity of the tincture of digitalis and mix them with two-thirds of water. Flannels soaked in this mixture are applied to the abdomen and thighs of the patient, and the flannels are covered up by a large wrapper of oiled silk. By per- sisting in the use of this measure, a very abundant supply of urine is often obtained. This is what you saw in our patient: in her, too, the diuresis led to resolution of the dropsy. Having a third time got quit of her symp- toms, she felt herself sufficiently well to leave the hospital. You see therefore that in this woman, the diarrhoea which I brought on for the purpose of getting rid of serious symptoms involving danger to life, became in turn a cause of exactly similar symptoms, and that 1 had con- sequently to contend against it. In another woman, whom you have like- wise seen in our clinical wards, suppression of the usual intestinal flux was the cause of death. This patient, like the first, came into our wards with an affection of the heart characterized by palpitation of the heart, with irregular frequency and inequality in the arterial pulse. On auscultation, I heard, at the apex of the heart, a sawing murmur accompanying the first sound, continuing during the short interval between the two sounds, and prolonged till the second sound. I diagnosed contraction with inadequacy of the mitral valve, and hypertrophy of the heart. The precordial dulness on percus- sion extended beyond its normal limits. The patient told me that for more than two years she had never been without diarrhoea; but she added, that she never was so well as when she had abundant diarrhoeal evacuations. Not paying much attention to this specialty, and not placing implicit confidence in the woman's statements, I endeavored to moderate the intestinal flux. My attempt was successful; but I bitterly regretted having made it, for great disturbance of the circu- lation soon supervened, and three days after the cure of her diarrhoea, this poor woman died. I am convinced that the profuse secretion from the intestinal surface was a discharge which protected the patient from the congestions and dropsies which usually accompany cardiac affections. As soon as I perceived the untoward symptoms occasioned by my inopportune medical intervention, I tried to restore the critical evacuation which I had imprudently checked: my attempts were unavailing. The case of the other patient of whom I have just been speaking would tend to show, that artificial critical evacua- tions are very far from being satisfactory substitutes for the evacuations which arise spontaneously. I have gone into these details to show you, how difficult it is to lay down general rules of treatment: to show that that which suits some cases is un- successful in others-that therapeutic measures of benefit in given circum- stances may fail subsequently even in the same subject-and that we must often seek to attain the same object by different means. Gentlemen, I have already told you that affections of the heart expose 708 ORGANIC AFFECTIONS OF THE HEART. physicians to the risk of making many mistakes-in this sense, that there is nothing so difficult as to form a prognosis of even approximate certainty as to their ulterior progress. I now add, that although it is generally easy, from the perfection which in'our day has been attained in auscultation and percussion, to ascertain the existence of heart diseases, their diagnosis still sometimes presents great difficulties. This may arise from the structural changes not manifesting themselves during the life of the patients by the physical phenomena which generally characterize them, as is proved by cases reported by Stokes of Dublin. And sometimes, as has been remarked by Dr. Beau, the examination of the dead body confutes our too precise diagnosis of a cardiac affection. Of this I only wish to lay before you two examples. Let me speak in the first place of a man in whose case I showed the morbid anatomical parts in this theatre. The patient was suffering from hypertrophy of the heart of old standing, and I thought that there also existed insufficiency of the mitral valve with contraction of the auriculo-ventricular opening. He had also had slight haemoptysis. Some of the sputa were tinged with blood: others were black and viscid, while others again were frothy and bright red. Finally, great general anasarca and ascites were added to the already seri- ous complications. The patient died three days after his arrival in our wards. On opening the body, I found that there was a notable increase in the volume of the heart. This hypertrophy involved the left ventricle, which was also dilated. I detected nothing abnormal in respect of the orifices, except slight thickening of the mitral valve, both segments of which, how- ever, seemed to play perfectly well, there being neither valvular insufficiency, nor any appreciable contraction of the auriculo-ventricular opening. One of the sigmoid valves of the aorta was ossified at its base, but it nevertheless adequately performed its office. There was, therefore, neither valvular insufficiency at, nor contraction of, the aortic The aorta was some- what dilated, and its walls presented incrustations similar to those upon the sigmoid valve. The reasons which influenced me in forming my diagnosis-insufficiency of the mitral valves and contraction of the auriculo-ventricular opening- seemed to me to be the natural inferences from the signs and symptoms now stated. When, as in our patient, there is only hypertrophy of the heart with dilatation, and no serious lesion of the mitral or tricuspid valves, the circu- lation generally remains regular. So it is also, when the sigmoid valves of the aorta are insufficient, a con- dition which is indicated by the bellows-murmur accompanying the second sound of the heart, heard at the base of the heart, prolonged through the arch of the aorta; by a remarkable vibratory character in the radial pulse; also, by greater force and fulness in the beat of the large, arteries, such as the carotid, humeral, and femoral. The absence in our patient of the physical signs which characterize insuf- ficiency in the aortic valves, although, in spite of the absence of bellows- murmurs, I detected all the phenomena which indicate lesions of the auriculo- ventricular orifices, viz., very great irregularity in the pulsations, also general anasarca, and a pulse, which besides being intermittent, was so exceedingly feeble as to make it impossible to count the number of the beats. By all these signs, I was led to my diagnosis. The autopsy proved my diagnosis to have been wrong; and showed that the symptoms observed during life, that the excessive disturbance of the circulation entirely depended on what Dr. Beau has called "asystolie"- ORGANIC AFFECTIONS OF THE HEART. 709 want of contractile power. I had certainly attributed to this asystolie the absence of the bellows-murmur characteristic of lesion of the auriculo- ventricular orifice; but I believed that it did not proceed from impaired muscular contractility of the heart, but from resistance to this contractility by an obstacle situated at the orifices. I based my opinion, I repeat, upon the presence of phenomena which I have described to you, and which are seldom associated with mere increase in the volume of the heart. There can be no doubt that I committed an error in my diagnosis; but I question whether it was an error which it would have been easy to have avoided. I confess that were a similar case to occur to me, I should be equally embarrassed, and should probably fall into the same error. In reality, the matter is not of much importance in a practical point of view: and here let me repeat a remark which I have already made, that the exact seat of a cardiac lesion is a study more interesting than useful. Apart from the reasons which I have mentioned, the occurrence of pul- monary apoplexy in our patient was an additional reason for believing that there was a lesion at the auriculo-ventricular opening, because it is in cases in which such lesions exist that pulmonary hemorrhage most commonly supervenes. • . The attack of pulmonary apoplexy was slight. At the autopsy, we only found a very small clot, about the size of a pigeon's egg, situated at the posterior part of the left lung. This accounted for its presence not having been revealed during life by auscultation, and explained why we had only heard some mucous subcrepitant rales unaccompanied by bellows-murmur or dulness. The patient had had albuminuria; and his kidneys presented all the characters of congestion. In this there was nothing extraordinary; for, as as you are aware, there is nothing more common than albuminuria in the last stage of disease of the heart. I say albuminuria and not Bright's dis- ease, which is a very different affection. Albuminuria is an expressive symptom met with in a great many diseases, such, for example, as typhoid fever, small-pox, scarlatina, and diphtheria-a symptom which may be transitory, and relate either to a temporary state of the kidneys or of the blood. Bright's disease, again, in which albuminuria is the predominant, or, if I may so speak, the specific symptom, is characterized by a structural change, irremediable and more or less profound, in the kidney. The pres- ence of albumen in the urine of individuals affected with diseases of the heart probably depends upon passive hyperaemic congestion, on engorge- ment, on hypostasis, which may take place quite as readily in the kidneys as in any other viscus, their vascular tension allowing transudation of the most liquid part of the blood, or, in other words, of the serum. There takes place in the urinary apparatus something analogous to that which takes place in other organs, in the cellular tissue, in the serous cavities in particular, where under the influence of the impediment to the venous cir- culation, we see passive congestions occurring, which give rise to dropsies. The second example which I wish to bring before you is the case of a woman who was received into the hospital with all the local and general symptoms of an affection of the heart. There existed an abnormal amount of dulness in the precordial region ; and a bellows-murmur, having its max- imum intensity at the apex of the heart, was heard, instead of the click of the valves. The pulsations of the heart were unequal in force, and the pulse was so quick that it could not be counted. There existed greatly embarrassed breathing and oedema of the extremities. The general symp- toms yielded to the treatment which I adopted ; but the serious character of the local phenomena continued, excepting that there was a diminution 710 ORGANIC AFFECTIONS OF THE HEART. in the rapidity of the pulse. The diagnosis which I had ordered to be inserted in the descriptive paper on the bed [la feuille d'observation] was- " valvular insufficiency, contraction of the auriculo-ventricular opening, and hypertrophy of the heart." This was also the diagnosis of those who were in the habit of following me in my hospital visit, and who had on many occasions, at intervals of some days, attentively examined the patient, as I had also done. I had no idea that I was mistaken ; when, upon one occa- sion (after having for some time discontinued to auscultate the heart), I was surprised not to find the bellows-murmur, previously so manifest. For eight days there was no return of this murmur, and the sound of the valvular click was only a little duller than in the normal state. There was, more- over, no return of the general symptoms. I certainly could not pretend to have cured the cardiac affection: I was well aware that when lesions of this kind attain a certain point, they do not improve: their remaining stationary is the most favorable result which can occur. To a certain extent, therefore, I was mistaken : the bellows- murmur accompanying both sounds of the heart very evidently indicated a morbid condition at the auriculo-ventricular orifice, an obstacle to the free play of the valves, which only imperfectly closed the opening, while, at the same time, there was a diminution in the calibre of the opening. There existed a permanent cardiac lesion, which was apparently a certain amount of thickening of the valves. There had been a temporary lesion, probably constituted by the vegetations, the presence of which upon the surface of the valves has been pointed out by Laennec, Professor Bouillaud, and others. Gentlemen, there can be no doubt that it is impossible absolutely to diagnose such lesions, but we may have good grounds for suspecting their existence. It is my opinion, therefore, that in our patient fibrinous con- cretions existed, which under the influence of a condition, probably inflam- matory, were deposited upon the already diseased valves, concretions such as are deposited-to use Dr. Bouillaud's happy comparison-upon the rods with which blood is whipped to separate its fibrin. These concretions interfered with the play of the membranous valves to which they adhered, and also narrowed the calibre of the auriculo-ventricular orifice, causing the bellows-murmur which we heard. The disappearance and non-repro- duction of the bellows-murmur must be ascribed to the opening being ren- dered free by removal of the partial obstruction, its gradual solution, and no new fibrinous deposit having taken place. I am unable otherwise to explain the production and cessation of the physical phenomena observed: but I admit that very serious objections may be urged against the validity of this explanation. This is no doubt an exceptional case ; but it is not unique in the annals of science. Such of you as have attended my clinic for some time must have seen patients presenting all the local and general symptoms of a very advanced cardiac disease-great anxiety, extreme depression, purple face, rapid and irregular pulse-recover from these symptoms, which admitted of no other explanation than a temporary obstacle to the circulation caused by polypiform concretions. Irrespective of symptoms resulting from the disturbance of the circula- tion through the cardiac cavities, there are others of a still more serious character which are generally consequences of fibrinous concretions in the heart or vessels : I refer to the symptoms caused by embolia. The term embolium, as you are aware, signifies a foreign body, which, formed in the heart, the arterial system, or the venous system, is launched into the torrent of the circulation, and obliterates more or less completely ORGANIC AFFECTIONS OF THE HEART. 711 the vessel in which it becomes impacted. The migration of clots in the vascular system is a fact to which attention was first called by Legroux, or at all events, he was the first to describe their migration in the arterial system. More recently, and particularly since the researches of Professor Virchow, the subject has been studied anew, and in a more complete man- ner.* Embolia, according to the importance of the vessels which they obstruct, may occasion more or less serious symptoms. Suppose, for example, that a fragment detached from the polypiform concretions of which I have just been speaking, be impelled through the aorta into the main artery of a limb, that it be there arrested in its progress, forming a plug by which an obstacle is presented to the passage of the blood, gangrene of the limb will be the consequence. The gangrene will be analogous to that very in- appropriately called senile gangrene, which is also the result of arterial oblit- eration. Suppose again, that the embolium stops the circulation in one of the principal arteries of the brain, you can readily understand that the consequences will be much more serious, and may even prove rapidly fatal. Some years ago, a young married lady whom I was at the time seeing in consultation with my friend Dr. Voillemier felt uncomfortable sensations in the region of the heart, and was afterwards suddenly seized with painful tingling in the fingers. The fingers had a bluish color, and very soon pre- sented all the appearances of a dry gangrenous affection : fortunately, the gangrene was limited to one of the last phalanges, which the patient lost. Eighteen months later, this lady was suddenly struck with complete paralysis of one side of the body, and subsequently sunk with all the symp- toms of softening of the brain. The age of the patient made it improbable that she had had an attack of simple apoplexy; the suddenness of the paralytic seizure, and the nature of the symptoms which had eighteen months previously shown themselves in the hand, led me to the conclusion that on both occasions something similar had occurred. On the first occa- sion, an embolium having obliterated an artery of the hand, caused partial paralysis of the finger ; and on the second occasion, an embolium penetrated the arteries of the brain and produced softening-a sort of cerebral gan- grene, of which hemiplegia was the characteristic manifestation. Nearly at the same time, a friend, quite a young man, was carried off by an attack of paralysis, which supervened under circumstances similar to those now described : the hemiplegia with which he was suddenly seized came on abruptly in the course of an attack of rheumatism of the heart. Two years previously, one of my colleagues was sent for to Bourges, to see a patient who had rheumatic endopericarditis: and in whom had sud- denly supervened gangrene of the great toe accompanied by coldness and purpling of the integuments. After death, which was not long in occurring, the popliteal artery was found completely obliterated by a clot. Similar facts have been recorded in different medical repertories. Dr. Worms has reported a case of acute endocarditis, followed by gangrene of the left leg caused by an embolium which had obliterated the trunk of the tibio-fibular artery. The patient was a soldier, 29 years of age. The gan- grene was complete, and involved the loss of the limb in which it occurred. The two lower thirds of the leg separated almost without any interference ; and six months after that occurrence M. Follin was obliged to give shape to the stump by an operation. Judging from what takes place in limbs attacked by gangrene, we may * Virchow : Uber die Verstopfung der Lungenarterie. [Froriep's Neue Notizen, 1846.] 712 ORGANIC AFFECTIONS OF THE HEART. conclude that the apoplectic attacks of which I have been speaking may originate in a similar mechanism. As the anastomosing arteries of the brain are so numerous and so large that the common carotid, and even both carotids, may be tied without occasioning either death or cerebral lesion, it is possible that in cases of embolism the apoplectic phenomena are the result, not merely of vascular obliteration, but of a more direct action of the clot upon the cerebral substance. Be that as it may, the disturbance of the cerebral functions is subordi- nate to its cause. Let me explain : if an embolium is only large enough to obstruct partially the vessel in which it is impacted, if it be of so slight a consistence as to admit of being disintegrated and dissolved, the obstacle which it presented to the current of the blood disappearing, the brain will resume its functions; but if, on the contrary, the embolium is large enough completely to plug the vessel, of a sufficiently resisting consistence not to break up and dissolve, there will ensue a real gangrene of the brain, and the cerebral softening may lead to death. You must remember a woman of 47 years of age whom we had in bed 4 of St. Bernard's Ward. She came into the hospital to be treated for disease of the heart; and my diagnosis was-contraction of the auriculo-ventricular orifice with inadequacy of the valves. I also found that there existed ascites and anasarca. The state of liver, which extended beyond the false ribs and seemed to be increased in volume, led me to believe that there was incipient cirrhosis. After some time, the condition of this woman had improved : the anasarca had disappeared, and the ascites had decreased ; when, in the beginning of December, suddenly she felt very acute pain in the right side of the head, and was struck with hemiplegia of the left side of the body. She retained consciousness up to death, which occurred erelong. My diagnosis was: softening of the brain, caused probably by obliteration of an artery. The autopsy was made on the following day at my request, and with the greatest possible care by Dr. Ludovic Hirschfeld, a very distinguished anatomist, now professor of anatomy in the medical university of Varsovia. The middle cerebral artery, which presented no trace of ossification, was completely obliterated by a clot of blood, black, homogeneous, and three centimetres in length: the branches going to the right corpus striatum, which was in process of softening, were also obliterated in the same way. All the other arteries were free from obstruction. I found also serious lesions at both auriculo-ventricular orifices, the valves of which were indurated, adherent, and insufficient. There also existed dilatation with hypertrophy of the heart. The cirrhosis of the liver which I had diagnosed certainly existed ; but the disease was in a much more advanced state than I had supposed. The increased volume of the liver was only apparent, the organ being •pushed down by the right lung, which was in a very emphysematous state. Bear also in mind the case of the recently delivered woman who occu- pied bed 20 in the same ward. The attendants attached to the ward informed us that on the evening before her admission to the hospital she ■had been struck by paralysis without immediate loss of consciousness: she had been able to say : " Take me to the hospital "-but on the day on which I saw her, she could not reply to any of my questions. I found that there was complete hemiplegia of the motor power of the right side, but no dimi- nution of natural sentient power. The pulse was frequent and irregular: auscultation of the heart enabled one to hear a bellows-murmur, having its maximum intensity at the apex, .beyond the.nipple. This murmur was harsh, and the mitral orifice was its ORGANIC AFFECTIONS OF THE HEART. 713 probable seat. Connecting those two facts-the lesion of the left side of the heart and the cerebral apoplexy-recalling to mind the beautiul researches of Virchow upon the migration of clots, and reasoning from the facility with which sanguineous coagula form in recently delivered women, and upon the rapidity with which the symptoms were developed in the case now under consideration, I had no hesitation in concluding that I had to do with an embolium situated in the middle cerebral artery of the left side, which had induced softening of the corresponding parts of the nervous centres. The patient, without having had any inflammatory reaction, without regaining consciousness, and without showing any change in the state of the paralyzed side, died eight days after her admission to the hospital. The autopsy fully confirmed my diagnosis. A portion of the brain in front of the left corpus striatum was softened : on the same side, the calibre of the middle cerebral artery, in the situation in which it expands into a dense vascular network, was obliterated, only, however, to the extent of two millimetres, by a small fibrinous clot, which was yellow, resistant, and did not adhere to the parietes of the vessel: all around this little fibrinous clot there was coagulated blood, which on the one side became lost in the anastomosing plexus of the middle cerebral artery, and which on the other side terminated abruptly at the origin of the artery of Sylvius. The little central clot which plugged the artery was like a millet-seed. There was no lesion of the walls of the middle cerebral artery. At the bifurcation of the left common carotid artery, there was a small fibrinous clot which also was of the size of a millet-seed, which sent three filiform prolongations, cruoric and fibrinous, one into the common carotid, another into the internal carotid, and the third into the middle thyroid. The mitral valve was the seat of conspicuous lesions. On the auricular surface of the valve, some adherent to the pericardium, and others so free as to be almost unattached, were warty-looking clots of different sizes. Gentlemen, it would be very difficult to avoid seeing that there was a rela- tion of cause and effect between the mitral lesion and the fibrinous clots found in certain cerebral arteries and the accompanying softening of the brain. Observe that the other arteries of the brain, examined with care, presented no intravascular coagulation, and that, except in the situation of the softening, the entire brain was normal in color and consistence. Finally, the similarity of form and the identity of structure of the fibrinous concretions of the mitral valve with those of the artery of Sylvius consti- tuted an additional reason in favor of embolism. With reference to the softening of the brain, I wish to remark to you, that most frequently the lesion of consistence and nutrition is seated in that portion of the left hemisphere supplied by the middle cerebral artery, or artery of Sylvius. I am not going to attempt to explain this fact to you, for were I to do so, I should only be entering upon an anatomical discus- sion of doubtful value. I would merely, in relation to our patient, remind you that my colleague, Dr. Broca, in his interesting memoir on aphemia, or the loss of articulate speech, has localized the function of speech in the posterior part of the third frontal convolution of the left side.* Let me also remind you that cerebral softening is most frequent on the left side, and in that portion of the brain which is supplied with blood by the artery of Sylvius. We are led by a consideration of these facts to see that there may be a relationship between an embolium, the seat of cerebral softening on the left side, and aphemia, * Broca: Bulletins de la Societe Anatomique. 1861. 714 ORGANIC AFFECTIONS OF THE HEART. or aphasia, as I have proposed to call the affection. This is a point to which I propose to return in future lectures.* To revert to the subject more immediately before us: it is now a well- established fact that migratory clots of a certain volume may, when lodged in the brain, or in other parts of the body, lead to softening or to gangrene: these results do not always take place when the clots are so small as to be only stopped in their passage through the capillaries. The consequent phenomena may then be of another kind. Capillary embolia seldom cause partial, very circumscribed gangrene, but often give rise to numerous ecchy- motic spots, small parenchymatous abscesses, and secondary deposits of fibrin, to which the name of visceral stuffing or infarctus has been given. The capillary embolia are the result of the breaking up of the clots, and dis- integration of the fibrin deposited on the cardiac valves; or, of the sponta- neous opening of atheromatous, fibrinous, or purulent cysts of the arteries. There are some cases in which the starting-point of embolia is ulcerous endocarditis, which at other times gives rise to symptoms of general poison- ing, leading to a typhoid state. This is a point which I propose afterwards to develop in lectures specially devoted to the subject.]" Here I will only remark that Professor Bouillaud, in his Traite des Maladies du Coeur, has reported a case of gangrenous endocarditis with ulceration and perfora- tion of the aortic valves; but both Professor Bouillaud, and Dr. Gigon (of Angouleme) who quotes the case, have only called attention to the morbid phenomena of endocarditis, and to the contraction of the orifice with inade- quacy of the aortic valves. Subsequently, Rokitansky, Virchow, Bamber- ger, and Friedreich in Germany, as well as Charcot and Vulpian in France,| showed that ulcerous endocarditis may be the starting-point of capillary embolism; and that it may also, by introducing morbid elements into the current of the circulation, give rise to symptomsofa general putrid poison- ing of the system so closely simulating, as to be liable to be mistaken for, the symptoms peculiar to typhoid fever and severe jaundice. Ulcerous endocarditis is more frequent in the left than in the right side of the heart: such at least is the conclusion arrived at from the cases col- lected by Bouillaud, Virchow, Bamberger, and Friedreich: Charcot and Vulpian, however, have published a case in which the valves of the right side of the heart were affected. To explain the symptoms of poisoning which occurred in that case, it is necessary to admit that the products of the ulcerative action in part had passed through the capillary vessels of the lung: such is the hypothesis enunciated by Drs. Charcot and Vulpian. But though we grant that the blood may be poisoned by the products of ulceration, it is not necessary to assume that they travel over the whole vascular system : it is sufficient that the blood in the right side of the heart come in contact with these products, to be changed to such an extent as to cause general poisoning. Just as the coincidence of an organic lesion of the heart with apoplexy leads us to infer that there is an embolium in the brain, so does the coexist- ence of cardiac symptoms with a typhoid condition, not depending on doth- inenteria, justify the supposition that there is ulcerous endocarditis. * See the lecture on Aphasia, p. 218 of the First Volume of the New Sydenham Society's translation. f See the lecture on Ulcerous Endocarditis. | Charcot and Vulpian: Cases of numerous Fibrinous Tumors containing Pu- riform Matter. \Comptes rendus des Stances et Memoires de la Societe de Biologic: Paris, 1854, p. 189.] Memoir on Fibrous Cysts containing Puriform Matter in two cases of Partial Aneurism of the Heart. [Second series, vol. i, 1854, p. 301.] ON VENESECTION IN CEREBRAL HEMORRHAGE, ETC. 715 I propose to study with you the subject of venous embolism-very common in cachexic conditions and in the prferperal state-when I come to lecture on phlegmasia alba dolens. LECTURE XXXIX. ON VENESECTION IN CEREBRAL HEMORRHAGE AND APOPLEXY. Apoplexy is not to be confounded with Hemorrhage.- Cerebral Hemorrhage rarely sets in with Apoplectiform Phenomena, properly so called.-Apo- plexy may be the expression of various grave lesions of the Encephalon.- Value of Facial Hemiplegia in Hemorrhage.-Inutility of Venesection, of Bloodletting in general, of Purgatives and Emetics in Hemorrhages and Apoplexy.-Differential Diagnosis between Softening and Hemor- rhage.- Value of certain signs with regard to Prognosis. Gentlemen: The patient lying in bed No. 7, St. Agnes Ward, affords me the opportunity of raising a question of the highest clinical impor- tance, namely, the contraindication of bloodletting in cerebral hemor- rhage, and more generally in apoplexy. I will at the same time draw your attention to the semeiotic value of facial paralysis when it occurs in connection with a lesion of the opposite hemisphere of the brain, and not as a consequence of disease exclusively limited to one of the facial nerves. Lastly, I will say a few words respecting the differential diagnosis between softening of, and hemorrhage into, the brain. The patient whom I mentioned just now, was admitted into the hos- pital for a chronic pulmonary catarrh, which had not caused any notable disturbance of his general health. He was under treatment for that com- plaint, when he was suddenly seized with symptoms which caused me some anxiety, although he did not himself complain of them. Without any premonitory headache or giddiness, he found a few days ago that his tongue was embarrassed, and that his speech was thick. His intellect was not in the least affected, his sight was perfect, his activity and his muscular strength were not diminished in the slightest degree; for his legs, at least, carried him, and moved as usual, and his gait was not vacil- lating. Having had occasion to write, however, he noticed, as soon as he took up his pen, that he had some difficulty in using it, and that his letters were not formed so well as usual. These symptoms excited so little anxiety in him that he complained to nobody, and that at my visit, on the following morning, he did not think of mentioning them. On coming near him, I was struck, however, with the alteration in his features; for there was evident deviation of his mouth. I questioned him, and then heard of the above-mentioned symptoms, which he had noticed on the pre- vious day. You heard him state and repeat that no intellectual disturb- ance, no affection of the senses, preceded or accompanied this thickness of speech, of which he was perfectly conscious, and the awkwardness with which he used the fingers of his right hand. You could study the character of the deformity of his face-how, on the left side, the labial commissure was markedly pulled upwards and out- wards, whilst it was lower on the right, the corresponding cheek being at 716 ON VENESECTION IN CEREBRAL HEMORRHAGE the same time flattened and almost motionless. At first, you might have thought that there was also deviation* of the tongue, for when the patient was asked to protrude it, the organ seemed to incline to the right of the middle line; but this deviation was only apparent, and was due to a change in the normal relations of the tongue to the aperture of the mouth from the pulling outwards and to the left of the labial commissure. The paralysis did not involve the face alone, for beside the awkwardness in writing noticed on the preceding day, there was weakness of the whole upper extremity on the right side, and he added, also, that he had had, that very morning, tingling sensations in the tips of the fingers of his right hand, which had lasted a minute or two. The sensibility of the skin was perfect and normal. Now, what is the matter with this man? I have no doubt that he is suffering from the effects of a small hemorrhage into the left hemisphere of the brain. Yet I acknowledge that, at first sight, the diagnosis offered some difficulty, for the case might have been thought one of facial paral- ysis only. It was the face that was chiefly affected, and the power of motion of the lower limb was perfect according to the patient, who averred that he noticed no difference between his right and left legs, and that on both sides he possessed as much strength as before. There was, indeed, undoubted paralysis of the right arm, but very slightly marked, involving limited movements only, and even then, it was on having occasion to write that the patient noticed the deficiency in the suppleness of his fingers. Not so with the paralysis of the face; this was evident to all bystanders, more so than to the patient himself, who was so unconscious of it that he did not complain of it. In this paralysis of the face, however, we already possessed an element of great value for making the diagnosis of Cerebral Hemorrhage, which I wrote on the card, because this paralysis of the facial muscles was not so complete as it usually is when it depends exclusively on disease of the seventh cranial nerve. In facial paralysis, caused by a lesion of one hemisphere of the brain, whether attended or not by paralysis of the limbs on the same side, the patient cannot perform with ease certain movements on the affected side, such as the act of blowing or getting back into the cavity of the mouth food which has lodged between the cheek and teeth, but he is not com- pletely incapable of performing such movements, and the difficulty he experiences is never so great as that felt by individuals suffering from pure facial paralysis. In the former case, also, the orbicularis palpebrarum is never paralyzed to the same extent as in the latter; hence, if a hemiplegic patient be asked to shut his eye, he does it completely enough to hide the globe of the eye, whilst the eyeball remains uncovered in cases of paralysis of the seventh pair. I do not attempt to find a reason for this difference; I merely note it as a fact taught me, long ago, by experience, and the importance of which, in making a differential diagnosis, you will immediately recognize. Thus, in this patient, the incompleteness of his facial palsy, in the absence even of other characteristic phenomena of a more extensive hemiplegia, sufficed to lead me to believe that the paralysis was due to some lesion of the left hemisphere of the brain, and not to disease of the portio dura. But this, gentlemen, is not the most essential point to which I wished to direct your attention. The patient had, I say, cerebral hemorrhage to a small amount. Observe that I do not use the word apoplexy, and pur- posely so, because there is a great difference between cerebral hemorrhage and apoplexy, although some confound them still, in spite of the majority of our classical authors who try to do away with this deplorable confusion. AND APOPLEXY. 717 Now, what is meant by apoplexy? According to its etymology, it means an affection in which, as the ancients described it, an individual falls, and is struck down suddenly, like an ox felled by the butcher. "Apoplexia dicitur adesse quandb repente actio quinque sensuum externorum, turn inter- norum, omnesque motus voluntarii abolentur, superstite pulsu plerumque forti, et respirations difficili, magna, stertente, und cum imagine profundi per- petuique somni." And if to this short sketch of apoplectiform phenomena, given by Boerhaave, you add the definition of Paulus Egineta, that this abolition of consciousness and of the sensibility of the whole body is caused by an affection of the sensorium commune (communi nervorum principio affectof you will know what is meant by apoplexy. You understand now why this term and that of hemorrhage should not be considered as synonymous. On the one hand, apoplexy is a generic term which must be specified, because apoplectiform phenomena are often con- nected with pathological conditions very different from hemorrhage. Thus, they may be the result of cerebral softening, of a rapid and more or less considerable accumulation of serosity in the ventricles and in the cerebral meninges, as in what is called serous apoplexy; or they may be due to con- gestion carried to the highest point, without actual extravasation of blood, as in what is termed ictus sanguinis (but in the next lecture I will show you how rare such cases are); or again, apoplexy may be produced, as the ancients had already noted it, by what we now term embolism. Lastly, it sometimes occurs independently of all appreciable lesion, on dissection, in the so-called nervous apoplexy. On the other hand, cerebral hemorrhage is not necessarily accompanied by symptoms of apoplexy; these show themselves only when the hemorrhage is pretty considerable. Small hemorrhagic clots can be formed, not only without the patient presenting the series of phenomena constituting apoplexy, but without his having any impairment of intellect, any affection of the senses; in fact, without any symptom indicating that the brain has been deeply modified in its func- tions. The only symptoms which then characterize the case are those of paralysis, more or less complete, and more or less limited in extent on the opposite side of the body. During the period that I have been in the habit of delivering clinical lectures at the Hdtel-Dieu of Paris, I have only seen one female and two male patients in whom cerebral hemorrhage seems to have set in at once with apoplectiform phenomena. You doubtless remember that rag-collec- tor who was found in the streets, and brought to the hospital in the most profound stupor, and laid in bed No. 5, St. Agnes Ward. He died on the second day after his admission, and when his brain was placed on the am- phitheatre table, I announced to you that we should find an effusion into the ventricles. It turned out that the blood had been first poured out in one of the corpora striata, from there had passed into the lateral ventricle of the same side, and after filling it, had broken down the septum lucidum, and got into the other lateral ventricle. During the summer of 1861 you saw in the St. Bernard Ward also, a woman, aged 63, who had had, the preceding year, a so-called paralytic stroke. She had faltered in her speech all of a sudden, and had been seized with weakness of one half of the body. There was, on that occasion, no loss of consciousness, no giddiness even. This time, she was found in her bed in a state of profound coma. She died without having been roused, and, as in the last case, there was found, in addition to the remains of the small hemorrhage of the previous year, an enormous clot, beginning in one optic thalamus, and distending both lateral ventricles. Again, you may still recollect that young man lying in No 15 bed, St. 718 ON VENESECTION IN CEREBRAL HEMORRHAGE Agnes Ward, who, whilst presenting all the symptoms of encephalitis, was suddenly seized with epileptiform convulsions, and died a few minutes after- wards in a state of earns. In this case there was hemorrhage into the pons Varolii, which had made its way into the fourth ventricle, and ruptured the valve of Vieussens. I repeat, gentlemen, apoplexy proper is very rare in cerebral hemorrhage. You have seen at No. 34, in the St. Bernard Ward, a very intelligent woman, 49 years old, who relates with perfect clearness her sad history. She was enjoying excellent health, when she noticed, one morning about eight o'clock, an impediment in her speech, and some numbness of her lee and arm. Feeling anxious at this, she walks down stairs from the third floor, and goes to a neighboring chemist's shop. She there takes a few drops of ether, and returns home with less facility, feeling the numbness rapidly increasing. On reaching the bottom of her stairs, she is unable to proceed further, tries to prevent herself from falling by resting against the wall, but drops down, nevertheless, without losing consciousness, or even feeling in the least giddy. Her neighbors came to her help, and brought her to the Hotel-Dieu. She was paralyzed on the right side. You have not forgotten, either, the woman lying at No. 10, St. Bernard Ward. She had just prepared and served the family dinner, at four o'clock in the afternoon. She was eating with a very good appetite in company of her husband and children, without any headache or other premonitory symptom that attracted her attention. All of a sudden she finds that she cannot cut her bread ; she says so to her husband, but with a thick voice. She tries to get up, and falls down with her chair, without losing conscious- ness or having felt giddy. As she is raised up she is found to be hemi- plegic, and on her admission into the hospital she relates herself the above details, with perfect clearness, and even with a certain degree of cheerful- ness. I insist on these two cases, because of the fall of both patients, the one on trying to get up from her chair, the other on reaching the foot of the stairs. This fall, I beg you to observe, differs essentially from that of a person struck down by apoplexy, but is analogous to the fall of a soldier whose leg is broken by a ball; inability to move the leg, and its extreme weak- ness, being the essential cause in both cases. The intellect is not affected, as it is in the apoplectic attack of epilepsy or of eclampsia. In the latter case, the individual drops like an ox knocked down by the butcher, and the phenomena which ensue are really those of apoplexy, such as described by our predecessors, phenomena which are observed in cases of cerebral hemorrhage only when there is effusion of blood into the ventricles, or the pons Varolii, or to an enormous amount in the centrum ovale of Vieussens, or again, into the arachnoid sac. I made use, just now, gentlemen, of a very restricted form of expression, when speaking of the rag-collector who had been picked up in the streets in a state of apoplexy. I told you that the cerebral hemorrhage seemed to have set in with apoplectic symptoms, as if I had some reason for doubting the accuracy of the fact. I doubt it, indeed, for if it be undeniable that the man was picked up and brought to the Hotel-Dieu in a state of apoplexy, and that the old woman I just mentioned was found one morning in her bed in a state of coma, who can positively affirm that these symptoms of apoplexy set in all of a sudden? In the spring of 1863 I was asked by my friend Dr. Marchal (de Calvi) to see a man, aged 63, who had had a fit that same morning. Whilst at breakfast, he had suddenly found some difficulty in holding his fork, and had felt slightly giddy. On attempting to speak, he noticed himself that AND APOPLEXY. 719 his speech was thick, and his children made the same observation. He staggered as he rose, felt weaker on one side than on the other, but, with the help of his son, managed to walk as far as his bedroom. He was then undressed and put to bed, he, all the time, understanding perfectly all that was being done, without any impairment of intellect, nor were his move- ments abolished. The hemiplegia made rapid progress, however, and be- came complete within half an hour. The intellect got gradually more and more clouded, and when Dr. Marchal arrived, half an hour or three-quar- ters of an hour after the setting in of the first symptoms, the patient was already in an apoplectic condition. Things went on from bad to worse, and when I came myself at five o'clock in the evening, the apoplectic stupor was at its height. In spite of the most energetic treatment, the patient died in the night. About the same date, I was fetched to see a patient of Dr. Revilloux, a man about 62 years old, who noticed, whilst at dinner, that one of his hands felt heavy ; he was not giddy, and only faltered in his speech. He tried to rise from his chair, but one of his legs being paralyzed, he fell down, with- out losing consciousness, however. His children lifted him up, and with their assistance he walked as far as the next room, and there sat on a chair. I arrived three-quarters of an hour after the manifestation of the first symp- toms. The patient retained, or seemed at least to retain, all his intellect. He answered me to the point, although his tongue was very much affected; and his left arm and leg were almost completely paralyzed of motion. Pro- found coma set in a few hours later, and death occurred the following morning. Very recently again, I admitted into the St. Bernard Ward a woman, aged 56, who had formerly been subject to the periodic headaches of gout, and who, eight months previously, had been seized one morning with the first symptoms of cerebral hemorrhage. She had gone out marketing, in as good health as ever; on returning home she noticed that she dragged her right leg, and that her right arm felt heavy. She even changed to her left hand a folded newspaper which she was carrying home, for fear of dropping it into the mud. She walked upstairs to her room, undressed, and got into bed. To questions of her husband, she replied in a faltering voice. The symptoms growing hourly worse, she became completely hemi- plegic, and partially unconscious towards evening. About twelve hours after the setting in of the illness, and for three days, she remained in a state of profound stupor. This case is interesting from other points of view also, and I shall return to it later; for, contrary to what usually obtains, the patient regained the power of moving her arm much more quickly and more completely than her leg, and I shall tell you what is the value of this sign. But to return to my proposition. In the case of the rag-collector and that of the old woman I spoke of before, who knows how the attack set in ? who knows whether for half an hour, an hour, and even more, the symp- toms had not run the same slow and progressive course as in the three cases I have just related to you ? Nay, I add that this is infinitely proba- ble, if not absolutely certain. The reason why I speak so positively is, because for more than fifteen years my attention has been directed to this point in the history of cerebral hemorrhage, and I never had the chance, never once, of seeing a patient struck down suddenly by apoplexy, in the classical and etymological sense of the word. I have not seen a single case in my hospital or my private practice, or in the practice of my pro- fessional brethren who have done me the honor of asking me to meet them in consultation. I have, indeed, seen a great number of individuals suffer- 720 ON VENESECTION IN CEREBRAL HEMORRHAGE ing from cerebral hemorrhage, in the most profound apoplectic stupor; but in every case, without exception, when the attack had occurred in pres- ence of witnesses, it had come on gradually, and had in general been slight at the outset, coma supervening ten minutes, half an hour, an hour, or several hours afterwards ; but in no single instance, I repeat, have I seen a man with cerebral hemorrhage struck down as by a blow, and drop- ping instantly in a state of unconsciousness. Under certain circumstances only is this the case, and I hasten to make the statement, lest my views should be deemed exaggerated or singular. The patient in No. 15 bed, St. Agnes Ward, who died of hemorrhage into the pons Varolii and tearing of the valve of Vieussens, became suddenly comatose, and remained so until his death, which occurred shortly after. But what did his night attendant tell us? The patient, you remember, had acute encephalitis, that would have carried him off a few days later had not this unforeseen attack occurred. All of a sudden he is seized with epileptiform convulsions, and he dies a few minutes afterwards, without having been roused from the most profound apoplectic stupor. Note well, gentlemen, that to the ordinary phenomena of hemorrhage there was super- added, in this case, an attack of convulsions, which alone, and apart from all complications, suffice for producing apoplectic stupor. I admit, then, that whenever cerebral hemorrhage begins with an epileptiform attack, apoplectic stupor will set in suddenly, as it does after every attack of epi- lepsy. I will add further, with regard to this case, that the hemorrhage was seated in the pons Varolii, that is, in a point where all the nerve- fibres converge. When hemorrhage occurs in a part so essential to life, I understand the suddenness of apoplectiform phenomena. But again, I repeat, apoplectic stupor is a very exceptional symptom of invasion in cases of cerebral hemorrhage, unless there be lesion of a central part, or an attack of convulsions. I make no exception even in favor of blood effusion into the lateral ven- tricles. Before this happens the blood has accumulated in a portion of the brain, near the surface of the ventricles, and has already given rise to symptoms which may have been mistaken, but which indicate, to the experienced practitioner, the existence of hemorrhage, or of a morbid pro- cess which has caused capillary hemorrhage. Suppose, for example, that such a morbid process takes place in a corpus striatum, and that in conse- quence of it a number of small clots have formed, varying from the size of a small pin's head to that of a small lentil, so far there will only be a sensa- tion of weight in the head, and of numbness in the side opposite to the lesion ; but if, all of a sudden, on the blood finding its way into a ventri- cle, the person falls down, struck with apoplexy, the symptoms noticed before the occurrence will be considered as premonitory only, whilst they were in reality symptoms of a simple or multiple hemorrhage, dating a few days back. In such a case the hemorrhage is supposed to occur only when the patient becomes apoplectic; whereas the blood is effused into the cere- bral substance at the time the first symptoms manifested themselves, the subsequent formidable accidents being caused by the sudden irruption of the blood into the ventricles. You saw what happened in the case of the patient who forms the sub- ject of this lecture. He had no warning when the hemorrhage began, and even after its occurrence there was nothing serious enough to excite his anxiety. He had only some impediment in his speech, some difficulty in writing, which alone attracted his attention, and a deviation of the mouth, of which he was not conscious before I observed it. If the suddenness with which the symptoms showed themselves, and their truly hemiplegic char- AND APOPLEXY. 721 acter, although the hemiplegia was limited to the face and the right arm, led us to infer that hemorrhage had taken place in the left cerebral hemi- sphere, the slight degree of impairment of motor power led us also to believe that the clot was very small, probably of the size of a lentil or a cherrystone. Now, such hemorrhages are not, by themselves, followed by fatal results, although they sometimes, it is true, indicate an unpleasant organic predisposition to the recurrence of similar accidents. By this organic predisposition I do not mean softening of the cerebral substance, which according to Rochoux, necessarily precedes hemorrhage, and which he accordingly considers as paving the way to it, and terms " hsemorrha- gipare," nor those changes in the cerebral vessels to which Abercrombie attributed the greatest share in the production of hemorrhage. Agreeing in this with the majority of medical men, I believe that the softening of the brain which accompanies hemorrhage is an effect, and not a cause. Its importance, however, is not the less great, for much more frequently than the hemorrhage itself, the sequential acute softening, the encephalitis, is the cause of grave cerebral accidents, and ultimately of the patient's death. As to the changes in the coats of the cerebral arteries, such as yellow laminse of cartilaginous consistency, mostly impregnated with calcareous salts, they cannot be an essential condition for the production of cerebral hemorrhages, since they are not met with in the greater number of cases, although present in some, as I have shown you instances. To return to our patient in the St. Agnes Ward, the symptoms in his case were so mild, that we were authorized to suppose the cerebral lesion to be unimportant, and to hope that the case would turn out favorably. In- deed, the man leaves the hospital to-day, feeling well enough to resume his usual occupation. Perhaps you have been surprised to see me do nothing in this case; and have you asked yourselves why, when so many others would have hastened to employ active treatment and had recourse to bleeding, either local or general, or both, purgatives and revulsives, I simply did nothing? Those who have seen my practice for some length of time have been less surprised because they know that I never use violent remedies, that I not only abstain from all energetic treatment when the symptoms of cerebral hemorrhage are as slight as they were in this case, but that I even refrain from >doing so in very grave cases, in fact, in all cases of apoplexy. My reasons are these: If I do not have recourse to bloodletting, purga- tives, or revulsives in cerebral hemorrhage, whether considerable or not, it is because experience has taught me that the patients do better without them. For when I reflect on what happens then, I do not see how those methods of treatment can be of any use, since the hemorrhage is an accom- plished fact when we are called upon to note its symptoms. What influ- ence, I ask, can be exerted on a foreign body in the shape of extravasated blood, by letting out blood from a vein of the arm, or of the foot, or from the jugular, or by dividing an artery, by cupping, or leeches ? Of what use are purgatives or revulsives ? It is said that bloodletting, and that pur- gatives, a kind of serous bleeding, empty the vessels, and thus facilitate ab- sorption of the extravasated blood; that they antagonize the cerebral con- gestion, which, according to the practitioners who recommend them, pre- cedes, accompanies, or follows, at the least, the extravasation of blood, and by thus preventing an exaggerated flow of liquid, they diminish the risks of the effusion becoming more considerable or occurring a second time. With regard to the first point, we may well doubt whether any difference obtains between cerebral hemorrhages and other hemorrhages, and, to take a very simple example, whether any difference exists between what takes vol. i.-46 722 ON VENESECTION IN CEREBRAL HEMORRHAGE place in cases of extravasation of blood into the cerebral substance and ex- travasation under the skin. In the latter case, has general or local blood- letting ever been seen to facilitate the absorption of the effused blood ? Do not most surgeons reject leeches, on the contrary, as being injurious, instead of useful ? An individual receives a blow, or falls on his head, for example, and the violent contusion produces a more or less considerable effusion of blood into the subcutaneous cellular tissue. Any medical man who may be sent for, will never think of prescribing anything more than cold lotions on the affected part, or using slight compression; and he does so, because he knows full well that futher interference would, to say the least, be super- fluous. Now, can we act more powerfully on ecchymoses of the brain than on those of the surface of the body ? Reasoning, therefore, agreeing with experience, pronounces useless the treatment against which I raise my voice. As to the second point, namely, that bloodletting is imperatively required with a view of arresting the molimen hemorrhagicum which caused the first symptoms, and might cause them a second time, it is indeed very doubtful. The part played by congestion seems to me to have been very much exaggerated, and although a great many practitioners believe gen- eral or local bloodletting to be so clearly indicated that there need be no hesitation in having recourse to it, I do not think that the necessity, nay more, the usefulness of the measure, has been clearly proved. Do we know well the organic conditions under the influence of which cerebral hemorrhage is produced? That congestion sometimes accom- panies it, is a fact generally accepted ; but is not this an effect rather than the cause of the extravasation of blood ? What influence then can blood- letting exert on this sequential hypersemia, when it has none on the foreign body formed by the effused blood, which is the starting-point of the deter- mination of blood? Furthermore, far from being useful, bloodletting has seemed hurtful to me, and I believe that it favors instead of preventing congestion. In the next lecture I purpose studying apoplectiform cerebral congestion, and I shall then tell you how I understand what occurs in apoplexy, and I shall speak of what I term cerebral surprise. I hope to be able to show you that apoplectic phenomena are in some measure more allied to syncope than to congestion, aud that bleeding is therefore contra- indicated, not demanded. This is what experience has taught me, and has taught others who follow in their practice the same rules as I do. What treatment then do I adopt in cases of cerebral hemorrhage, and more generally in apoplexy ? Instead of bleeding my patients, of putting them on low diet, and keeping them in bed, I do not draw blood from them, I recommend to them to get up if possible, at least to remain in the sitting posture, and I feed them. I am convinced that I thus obtain much more favorable results than when I interfered more actively, and that patients so treated do a great deal better than those whom I bled in former days, kept on low diet, and confined to their beds. I reject bloodletting from the treatment of cerebral hemorrhage, al- though I think that very plausible reasons are urged by those who act differently from me. I did myself for a long time what most practition- ers still continue to do now7, and I used to think my plan very rational. I may add that, in spite of ourselves, we feel the influence of fashion, how7- ever sad the confession may be. I began practicing medicine at a time when the doctrines of Broussais were in all their glory; and although I had been a pupil of Bretonneau, who had dealt the heaviest blows to the doctrines of the illustrious physician of the Vale de Grace, I felt not the less the powerful influence of those doctrines, and I was induced to pre- scribe leeches in cases where I never think of doing so now7, merely because AND APOPLEXY. 723 everybody did it, and because no amount of self-confidence can make one believe he is right when he is in opposition to everybody else. I bled, therefore, in cerebral hemorrhage, because bleeding was used before and around me. Now that I have reached an advanced age and that I occupy a position which allows me freely to follow my inspirations, I still understand how a young practitioner has neither courage nor self-con- fidence enough to reject a mode of treatment which has been in some measure sanctioned by the experience of several generations of medical men. But there is another circumstance which renders non-interference still more difficult-I mean, the febrile action, which rarely fails in hemorrhages of a certain amount. This febrile action, on which classical authors lay too little stress, usually commences from twenty to twenty-four hours after the outset of the attack, and reaches its maximum on the second or third day. The pulse becomes hard and frequent, the skin hot and often bathed in perspiration, the face flushed, respiration labored. I confess that I have been induced to bleed under those circumstances when I had refused to do so in the beginning ; but I must confess also that the bleeding has never seemed of any use to me; that it has often been manifestly injurious, and that if I had the courage to resist the seemingly pressing indication, the fever ceased, and the patient regained his strength with a much greater rapidity than if bloodletting had been had recourse to. In such cases, I still better understand how difficult it is for a young practitioner not to yield to the apparent urgency and to the entreaties of the friends who ask for bleeding, as well as the advice of brother practitioners who regard it as necessary. And as in a certain number of cases, this fever lighted up on the second and third day, and the cause of which I cannot well explain, only ushers in formidable brain symptoms which become rapidly fatal, I understand that antiphlogistics may be thought of, although they prove useless, alas ! when the disease runs the course I just mentioned. To save your responsibility in such cases, avoiding at the same time what your con- science forbids, open a vein, but in such a way as only to draw an insig- nificant quantity of blood and explain to the friends that it would be dan- gerous to go further. In many cases there will be real danger in doing so, for some persons have been seized with fearful symptoms even after a moderate bleeding. A short time ago, a gentleman, a former pupil of mine, was sent for to a magistrate who had just been struck down with cerebral hemorrhage. There were well-marked hemiplegia, distortion of the face, and impairment of speech ; the intellect was perfect. Although he was of opinion that bleeding was not required, he was compelled to yield to the consulting physician, who had over him the superiority of age and of a high scientific position. The patient was therefore bled; but he had scarcely lost 100 gramme's of blood (about three ounces) when he fell into a state of complete resolution, from which he never rallied, until his death, which occurred a few days afterwards. But a moment before the bleeding he was in the full enjoyment of all his faculties, and conversed freely and. ably with his friends around. I am not the only one, gentlemen, who regards bleeding, and the other means usually recommended in cerebral hemorrhage and apoplexy, as useless and inconvenient. Very recently one of my colleagues, Professor Monneret, declared that he had for a long time given up the active treat- ment which, like myself, he formerly had recourse to. Far from lowering his patients, he feeds them, and gives them wine. Since I have conformed to the rule of keeping up the strength of my patients by giving them food in moderation, I find that the bad symptoms under which they labor dis- 724 ON VENESECTION IN CEREBRAL HEMORRHAGE appear more rapidly than when I interfered actively, and the case you have lately had occasion to observe is another proof in favor of my asser- tion. ' In the case of the patient in the St. Agnes Ward, there supervened, in the course of his illness, certain phenomena to which I wish to draw your attention. You often heard him complain of attacks of giddiness, which were more or less prolonged ; and, doubtless, many among you looked upon them as symptoms of a determination of blood to the head, and concluded that if I had bled the patient I would have avoided those threatenings of returning hemorrhage. On carefully questioning the man, however, I found that the giddiness came on more frequently when he had been fast- ing, and ceased immediately on his taking food. It was not cerebral congestion, therefore, at least, congestion as it is generally understood, which caused the symptoms I alluded to. These were due to a deficiency in the normal constituents of the blood, unfitting it for stimulating the brain, and not to an excess of blood in the vessels. Bleeding would have aggravated this vertiginous disturbance, whereas nourishment speedily got rid of it. Since we are on the subject of cerebral hemorrhage, allow me, gentle- men, to take the opportunity of speaking to you of softening of the brain, and of answering, to the best of my ability, the questions you often ask me in the course of my visits round the wards, embarrassing questions though they be, because you expect me to solve one of the most difficult problems in pathology, namely, the differential diagnosis between cerebral hemor- rhage and softening. Lying at No. 18, in our male ward, is a patient whose history is interesting from this very point of view. He was admitted into the hospital a few days ago, suffering from complete hemiplegia of the right side. His history is very short, and is as follows: He was seized in the midst of the most perfect health, with the exception that for the last eight or ten days he had suffered from occasional giddiness and headache, and had felt confused at times. He had also noticed a sensation of numb- ness in his right hand and foot. He was not, however, prevented from walking or moving about, and attending to his usual occupation, when suddenly, a few days ago, he was struck with palsy of the right side. He then came to the Hotel-Dieu, where I found complete paralysis of motion, with relaxation of the right arm and leg, involving the corresponding half of the face, besides nearly absolute anaesthesia of the integuments of the affected parts, marked dulness of aspect, and slowness of speech. The patient was free from fever. I thought that cerebral hemorrhage had occurred in this case, although I felt some hesitation at first, because of the complete loss of the power of motion, and the thorough resolution of the limbs on the right side, that were scarcely proportionate to the small degree of intellectual disturbance. Indeed, it does not usually happen, in my opinion at least, that in cerebral hemorrhage there should be such complete paralysis of motion as there was in this instance, without there being loss of consciousness also. Complete loss of motor power, without accompanying coma at the time of seizure, belongs, I believe, more especially to softening. On many occasions, and for many years, I have specially called your attention to these elements of a differential diagnosis between hemorrhage and softening, diagnostic char- acters laid down by Recamier, and for which I claim no credit to myself. According to my illustrious teacher, the value of actual symptoms is infi- nitely greater than that of the phenomena which in some cases precede the attack, although he does not deny that they are of some value. Recamier, indeed, affirmed, and in many cases I have been enabled to verify the truth AND APOPLEXY. 725 of his proposition, that whenever hemiplegia, complete and absolute, occurs suddenly (and I insist on this point-the suddenness of attack), without loss of consciousness, softening of the brain may be diagnosed. Whenever, on the contrary, the complete loss of motor power is attended by loss of consciousness, whenever, especially, the individual has become suddenly comatose, hemorrhage may be diagnosed, and hemorrhage to a considerable amount. But when the intellect is affected to some extent, but not entirely- when there is obtuseness, but not complete loss of sensibility-whilst there is absolute loss of motor power, as in the case of our patient in St. Agnes Ward, we must always, according to Recamier, diagnose hemorrhage in connection with softening, or what has been termed capillary hemorrhage. This latter form usually takes place in a softened portion of the brain, and is characterized, on dissection, by the presence either of a large number of small clots, perfectly isolated from one another, or coalesced so as to form larger hemorrhagic centres. In those cases, but in them alone, was the eminent physician of the Hotel-Dieu disposed to admit the antecedent soft- ening which is by Rochoux regarded as the organic condition, the morbid process which must of necessity, and in all instances, precede cerebral hemorrhage. I am too much a pupil of Recamier, I confess, not to adopt his conclusions, which my personal experience seems to me, besides, to have corroborated, in the case I have just alluded to. I am therefore inclined to diagnose hemorrhage connected with softening of the brain. The grounds on which I rest my belief are, that the patient never suffered from the grave disturbance of the intellect, the loss of consciousness, the coma, or the somnolence at least, which usually accompany hemorrhage of great magnitude; that he only felt a little confused, bewildered, and stupid, which symptoms coincided with a diminution in the cutaneous sensibility of the side, which was completely paralyzed of motion. When speaking to you of the female patient lying in bed No. 11, St. Ber- nard Ward, I said that I wished to call your attention to an unusual symptom which she presents, a symptom to which, I believe, sufficient im- portance is not given, as influencing prognosis. She told you, and we verified her statement, that she could move her arm better than her leg, and she added that for a few mouths after her seizure she had walked much better than she does now. You know that the reverse usually obtains, and that in the great majority of instances the lower limb regains the power of motion much quicker than the arm. Why it is so I do not know, and I am not aware that anybody has ever given a satisfactory explanation of it. This is remarkable, however, that when the arm regains power quicker and better than the leg, the patient is w'orse off than when the reverse obtains. Three years ago, I was sent for to see a general officer, a near relative of mine. He had been seized that morning, a little before breakfast, with paralysis of the right side. For three or four days after this his symptoms looked unfavorable, but fever soon ceased, and a fortnight after the attack he could write, shave himself, and w7alk pretty well. The extreme preci- sion of the movements required for writing and shaving showed clearly enough that his arm was considerably better than his leg, for he walked very lame. After the lapse of a few months his leg became stiff and pain- ful, and he walked with more difficulty. A stick was no longer enough for him, and he required the help of a friend's arm ; later, even with this help, he was unable to walk. At that time the arm itself began to lose power, and the intellect failed in proportion. Subsequently, the poor man could not leave his arm-chair, and suffered excruciating pain in the para- lyzed side, especially in the leg. He at last died in a state of perfect im- becility. 726 ON APOPLECTIFORM CEREBRAL CONGESTION, The same fate awaits the woman in the St. Bernard Ward. She, too, uses her arm much better than her leg; but already, for the last two or three months, her leg, at night especially, has become acutely painful. For two months after her seizure she walked pretty well, whereas, now, she cannot take a single step unless strongly supported, and before another two or three months shall have elapsed, she will probably not be able to leave her arm-chair and she will die within the year consumed by pain, and a thorough imbecile. Now, gentlemen, if you ask me why our prognosis should be unfavorable when the arm regains power more completely and more rapidly than the leg, I must confess my ignorance, and content myself with noting a fact which has often enough occurred in my practice to have attracted my at- tention. I cannot say whether a morbid process goes on round the clot, causing chronic softening or irregular cicatrices; but whatever the cause may be the fact remains, and seems to me to possess some value. I will not leave this subject without calling your attention to another sign, which, like the preceding, is of great prognostic value. You doubt- less remember two women, the one, still young, lying in No. 34 bed, St. Ber- nard Ward, the other, aged 64, lying in bed 28. They were both paralyzed on the left side after an attack of cerebral hemorrhage. There had been no impairment of intellect, and they both could walk before a month had elapsed from the date of seizure. I drew your attention at the time to the fact that the fingers of both these women were flexed into the palm of the hand through permanent contraction of the flexors, and I told you then, as it has since unfortunately happened, that they would never be able to use their hands : that the extensors would never regain the power they had lost, that the hand would always look like claws, and the power of motion in the upper limb would be almost completely abolished. This is another fact taught by clinical experience which you should not ignore, because you must not hold out the promise of cure, or even of im- provement in such cases, as the symptoms, far from getting better, will grow worse with every succeeding year. LECTURE XL. ON APOPLECTIFORM CEREBRAL CONGESTION, AND ITS RELA- TIONS TO EPILEPSY AND ECLAMPSIA. § 1. The existence of Cerebral Congestion is not contested; but it has been singularly abused, in order to explain Cerebral Phenomena in the produc- tion of which Congestion plays no part whatever.-Sudden and transient fits of Apoplexy are among these, and the so-called Apoplectiform Cerebral Congestions are oftener connected with Epilepsy than is generally believed. -A few considerations on the sudden and irresistible impulses of Epi- leptics in general, and on the inferences to be drawn from them in a medico-legal point of view. Gentlemen : Apoplectiform Cerebral Congestion is a term usually applied to a group of transient phenomena occurring suddenly, and resembling those of apoplexy properly so called. These latter are well defined in the aphor- ism of Boerhaave, which I have already quoted in the preceding lecture; AND ITS RELATIONS TO EPILEPSY AND ECLAMPSIA. 727 namely,-" Apoplexia dicitur adesse, quandb repente actio quinque sensuum externorum, tiim internorum, omnesque motus voluntarii abolentur, superstate pulsu plerumque forti, et respiratione difficili, magna, stertente, una cum imagine profundi perpetuique somni" When these apoplectic phenomena are transitory, the case is said to be one of apoplectiform cerebral congestion; when they are persistent, cerebral hemorrhage is, in the majority of cases, supposed to have taken place to a large amount. It is a current opinion, as you are well aware, that apoplec- tiform cerebral congestion is a common complaint, and this opinion is so generally accepted, so firmly established, that it seems strange for any one to appear to doubt it. During the first years of my practice I saw, or thought I saw, a pretty large number of cases of apoplectiform congestion, but fora longtime I have not seen any; yet other medical men see as many as before. Let us, therefore, inquire on whose side the error lies. A man, for instance, with or without premonitory symptoms, falls down suddenly in an apoplectic condition. When picked up he looks stupefied, and for a quarter of an hour, an hour, or perhaps more, he complains of heaviness of the head and mental confusion, and staggers in walking. On the next day all these symptoms have disappeared. In such a case the patient is said to have had apoplectiform cerebral congestion. I used to say so like the rest, but I do not now. Another man, whilst walking, is suddenly seized with giddiness. He loses his sight and the faculty of speech, merely muttering a few unintelli- gible words. He staggers, and sometimes falls down; but rises immediately. The whole set of symptoms have occurred within a few seconds, and are followed by a slight heaviness of the head only, and sometimes by transient mental confusion; but after three or four minutes he is as well as before. Such a case is said to be one of slight cerebral congestion. I also used to say so, but no longer say so now. Why, then, have I altered my views, gentlemen? Not, certainly, from a love of paradox; but because facts have forced on me a new conviction. In the year 1845 a friend of mine was found in his bed in a state of insen- sibility. His face was turgid and livid, his intellect in abeyance, and all power of motion and sensation completely lost; there was stertor also. He was a vigorous man, aged 42. How long he had been in this condition his wife could not tell; for she had been awakened by a strange snoring noise, and she had sent for me. I had already, at that time, given up bleed- ing in the treatment of apoplexy. I had the patient placed in a half-sitting posture, and threw cold water in his face. I also applied two ligatures round the upper part of his thighs, in order to retain temporarily a large quantity of venous blood in the vessels of the lower limbs (although I in reality expected little from the measure), and I waited. An hour scarcely elapsed before the patient regained the power of motion and feeling, and answered questions pretty well to the point. On the following day, great lassitude was the only symptom remaining. Some time afterwards I was fetched in haste to see a neighbor, aged 70, who had been seized with apoplexy on the Boulevards. He had been in- sensible for a quarter of an hour, but was recovering his senses as I arrived. He did not yet recognize me, however, and looked vacantly round, moving his arms and legs about, without being conscious of it. His lips and nose were swollen, his eyes injected. By degrees, and within a few hours, he recovered entirely, without my having had recourse to any active measures. His valet then informed me that his master had, in the last two or three years, had several attacks of the same kind, and that the symptoms had passed off in the same way, once after bleeding, and on the other occasions 728 ON APOPLECTIFORM CEREBRAL CONGESTION, after a mustard foot-bath. In the same year I was consulted by a solicitor from the country, aged 35, wffio in the course of the previous six months had suffered from three apoplectic fits. He had been bled and purged on each occasion, to his great satisfaction, and leeches were applied once a month round his anus. The last attack had occurred as he was going up a staircase to his apartments, on his return from some important pleadings. His head had struck against the stairs, and there were still on his forehead the marks of a pretty deep cut. The apoplectiform phenomena had lasted an hour at the most; and when I saw him, his intellect, sensibility, and power of motion were perfectly normal. I can with difficulty believe that apoplexy occurs in persons aged 35, particularly when the attacks return every two months. It immediately occurred to me that the case was one of epilepsy, and I suggested it to the medical man who had sent the patient to me. His answer was that nothing authorized my suspicions, and that convulsions had never been noticed. I still maintained myopinion, however; and shortly afterwards the poor man had, in court, a regular epileptic fit, which unfortunately left no doubt in anybody's mind, and he was compelled to give up his profession. But my attention had now been roused; I asked myself whether so many persons whom I had seen with apoplectiform cerebral congestion were not epileptics, and I kept on the watch. My first patient soon had other attacks, and he now has sometimes as many as four or five epileptic fits in a day, and very often the vertigo of petit-mal. He has lost his sight, and his mind is considerably impaired. As to the old man whose history I have related to you, he is still living, and has almost every year one or two similar attacks. Since the day he fell down on the Boulevards, he never goes out unless accompanied by a servant, who has informed me that his master makes grimaces when on the ground, and has startings in one of his arms, which last scarcely a minute, but are amply sufficient to characterize epilepsy. Since that time, whenever I have been consulted for a case of apoplec- tiform cerebral congestion, I have inquired with the greatest care whether, from time to time, there were, during the day, sudden and transient attacks of vertigo, having the characters I have indicated above, and whether those congestive seizures occurred more frequently at night than in the day- time, and whether also there had been nervous twitches in the beginning of the attack. In every case almost, when the seizures had occurred in the presence of witnesses, convulsions could be made out. When they had taken place in the night, and during sleep, I was told that the urine had been sometimes passed involuntarily, and that for a few days the tongue had been sore. The face, forehead, and neck had often been covered with small ecchymoses, looking like flea-bites. I was told particularly that the attacks recurred at pretty short intervals, and left no lasting traces. In a wTord, epilepsy became plain when it was sought for. Not a month elapses without my seeing, in my consulting-room, patients suffering from epilepsy, who are said to have had apoplexy. Not a week, perhaps, goes by without my being consulted by adults and old people, or for children, affected with epileptic vertigo, who are said to be suffering from slight cerebral congestions. Although epilepsy, in all its forms, is better known now than five-and-twenty or thirty years ago, yet many prac- titioners will not believe in so terrible a disease; and even if they recognize it, they will not tell the patient's friends the real nature of the case, and prefer to leave the painful task to the consulting physician. Very frequently, epileptic vertigo gives rise to symptoms usually attrib- uted to cerebral congestion; symptoms to which attention has long been AND ITS RELATIONS TO EPILEPSY AND ECLAMPSIA. 729 drawn by those who specially devote themselves to the treatment of the insane. After an attack of vertigo, the patient is frequently delirious for a few minutes, and perhaps longer. The records of courts of justice and of police- offices are full of cases of suicide and of murder, too often attributed by medical men to what they call cerebral congestion, but which should be ascribed to epilepsy. It may be said, almost without fear of making a mistake, that if a man suddenly commits murder, without any previous intellectual disturbance-without having up to that time shown any symp- toms of insanity, and if not under the influence of passion, or of alcohol, or any other poisonous substance which acts with energy on the nervous system-it may be said, I repeat, that the man is afflicted with epilepsy, and that he has had a fit, or, more usually, an attack of vertigo. The reason why these strange acts are attributed by most medical men and by magistrates to passing cerebral congestion, is that the epileptic seizure is sometimes mistaken, and that the vertigo is almost always so. I never pretended, gentlemen, that because a culprit is epileptic-he should be exonerated from all criminality. Let a barrister use this argument; let him pretend that his client was not a free agent at the moment when the criminal act was committed; I grant it, but I will never, for my part, dare support such a doctrine before a court of justice. I am perfectly convinced that many epileptics are great criminals in the moral sense of the word, and that the acts of which they are guilty have been premeditated, and com- mitted by them as free agents. But in such cases, the preparations for, and the perpetration of the crime, are in nothing different from what usually happens. The epileptic, if not insane in the interval between his fits, is like any other man, and as such is amenable to the laws. On this point no difference of opinion exists. But if this same individual has committed a murder, without any possible motive, without profit to himself or any other person, without premeditation or passion, openly, and consequently in a manner quite different from that in which crimes are usually commit- ted, I have the right of affirming before a magistrate that the criminal impulse has been the result, almost to a certainty, of the epileptic shock. I would say almost, if I had not seen the fit; but if I myself, or others, had seen a fit or an attack of vertigo immediately precede the criminal act, I would then affirm most positively that the culprit had been driven to the crime by an irresistible impulse, and he would be absolved by virtue of Art. 64 of the Penal Code. It would be a mistake to believe that epileptics have sudden and irre- sistible impulses in the interval, and independently of the fits. When insanity has been brought on by epilepsy, as is, unfortunately, very com- mon ; when acute mania follows, for a few days, on a convulsive fit, no doubt can exist; and persons so afflicted are rarely brought before a court of justice if they commit a crime or misdemeanor. Where dementia is evi- dent, the law does not punish. The magistrate orders the man to be con- fined, because he owes protection to society that is menaced, and to the poor madman himself, who is legally incapable. But the epileptic shock can strike at the will. The perfect intelligence of the epileptic immediately before and shortly after the attack, his absolute moral liberty in the interval between his fits, can alone make him appear guilty. Those, then, are the conditions which should be studied. In general, the question of guilty or not guilty is not raised when the crime or misdemeanor has been committed immediately after a fit, when those who witnessed the crime also witnessed the convulsions, any more than it is in the case of a maniac confined in a lunatic asylum, or of an 730 ON APOPLECTIFORM CEREBRAL CONGESTION, hospital patient under the influence of delirium, who may commit any acts of violence. It may happen, however, that the fit does not occur in pres- ence of any witnesses, or that the acts which are committed soon after are not seen by those who witnessed the fit, and then doubts may arise. The following case was related to me by Dr. Jozat: A young man, whilst on his ,way to the Palais Royal, in company of some friends, with whom he was going to dine, suddenly falls down on the " Place Louvois," but soon gets up again, and rushes on the passers-by, striking them with violence. He is taken to the police-station, and for some time keeps insult- ing the'soldiers who hold him, and spitting in their faces. Now, had there been no witnesses of the epileptic attack which had preceded this extraor- dinary scene, and bad not the physician who related the fact to me, inter- fered, the young man would have been tried for rebellion against the police authorities. It will be easily conceived how difficult it is to arrive at the truth, when the epileptic and the victim of his violence have been quite alone. And on this point allow me to bring before you a certain number of cases that fell under my own observation, and for the truth of which I can vouch. I was very recently consulted by a newly-married couple. The lady told me that, shortly after her marriage, she had been awakened one night by strange movements of her husband, who had suddenly struck her with awful violence. Had she not managed to ring the bell, she added, and a maid-servant rushed in and delivered her, she might have been seriously hurt. Another scene, of the same kind, had again taken place a few days before I was consulted; but on this occasion she awoke in time, lighted a candle, and saw the convulsions with which her husband was seized. Flight saved her from the violence which immediately followed. These details were told me in the presence of the poor man, who was per- fectly conscious of having felt something that he could not account for, and who now informed me that he had often, before his marriage, had attacks of vertigo, the character of which had not been recognized by the medical men whom he had consulted. I have still in one of my wards at the Hotel-Dieu a young girl, of a quiet and gentle disposition, who sometimes has, within the twenty-four hours, as many as a hundred attacks of petit-mal. On the night of her admission she was put in a separate room, with a very intelligent nurse. About the middle of the night, she got out of bed after an attack, and began to beat the nurse, who woke in a fright. Scarcely half a minute elapsed before the patient recovered her senses, and got into bed again, ignorant of what she had done. You have all heard, without doubt, of that highly intelligent lady, and perfectly respectable in every respect, who, in a drawing-room, at a theatre, in church, or when walking out, suddenly makes use of most insulting or obscene expressions, of which she is said to be unconscious. I have myself known a very intelligent magistrate, of whom I shall speak again by and by, who was subject to frequent attacks of epileptic vertigo. His sister had been confined at Charenton, where I knew her. He was president of a provincial tribunal. One day he gets up all of a sudden, mutters a few unintelligible words, and goes to the deliberating-room. He is followed by the usher, who sees him make water in a corner. A few minutes afterwards he returns to his seat, and again listens with intelligence and attention to the pleadings, momentarily interrupted. He had no recol- lection of the incredibly incongruous act which he had committed. I could cite an endless number of similar instances, borrowed from my own practice and that of others; but I wish to answer one of the gravest objections made by medical men, and still more by magistrates, to the theory of sudden and irresistible impulses in some epileptics. The disturb- AND ITS RELATIONS TO EPILEPSY AND ECLAMPSIA. 731 ance of the reason which follows a convulsive fit, and especially an attack of vertigo, is not always recognized so easily as it might be supposed. A medical man, for instance, is sent for to see an epileptic immediately after an attack. The patient answers questions pretty well to the point, follows out the doctor's prescriptions, takes a foot-bath, allows himself to be bled or leeched, and describes his feelings pretty accurately ; but a few hours later he has not only forgotten what occurred during the attack, as the rule is, but he has even forgotten all the above circumstances, in which he had apparently concurred with so much presence of mind. It must, there- fore, be concluded that his intellect had been deeply perturbed. Who, nowr, can calculate the degree of liberty possessed by a man in this state of transition between the actual attack and the complete recovery of the mental faculties ? Is there a medical man bold enough to pronounce on this point, and to affirm that a crime committed after the attack must entail responsibility ? Not only, gentlemen, may the patient's reason remain in a perturbed condition for some time after the attack, although a superficial observer may not perceive it, but it sometimes happens that, during the attack, the epileptic seems to retain enough reason to appear free. Allow me to cite a few instances in illustration. The young girl now in my ward, to w-hom I alluded just now, goes, during her attacks of vertigo, through certain acts that require, in some measure, liberty and intelligence. If, at the outset of the attack, any one snatches from her an object she is holding, she rushes on him to regain possession of it, pursues him without staggering, without stumbling or knocking against anything in her way, and is even violent if she be re- sisted ; then, all of a sudden, before half a minute has elapsed, she exclaims, " It is over," stops, and falls into a state of prostration. If questioned at once, she has no recollection whatever of w'hat has just occurred. When I treat more particularly of epilepsy, I shall detail to you the case of a young man, a great musical amateur and very skilful- violinist, who is afflicted with epilepsy. He is so passionately fond of music that he plays second violin at some theatres without any remuneration. He has often been seized with vertigo whilst playing a piece ; but during the attack, wfflich does not last more than ten or fifteen seconds, he continues to play in perfect time. He then comes round, knows full well that he has had a fit of absence, and continues to play without difficulty. The lady whom I mentioned just now as being liable to singular and irresistible impulses, prompting her to use, without her being conscious of it, most strange expressions, makes in a loud voice witty and pointed remarks, contrary to the rules of society. But, although she acts under the influence of an irresistible impulse, her remarks are so perfectly appo- site, however, that persons, not familial- with the phenomena of epilepsy, must incline to believe that they are made intentionally. If, instead of insulting or obscene expressions, or epigrams, you substitute murder, say whether there would be crime, and whether, in such a case, the article 64 of the Penal Code would not find its application ? The magistrate concerning whom I told you such a singular anecdote, remained for some time in a disturbed mental condition after an attack: but this state was noticed by his wife alone, who was an excellent judge of it, and watched him with great solicitude. He belonged to a literary society, which held its meetings at the Hotel de Ville of Paris. At one of these, during a discussion on an important historical point, he is seized with vertigo. He runs quickly down to the Place de 1'Hotel de Ville, and walks about for a few minutes on the quays, avoiding with success both carriages 732 ON APOPLECTIFORM CEREBRAL CONGESTION, and the passers-by. On recovering himself, he perceives that he has come out without his great coat and his hat, returns to the meeting, and resumes, with a perfectly lucid mind, the historical discussion in which he had already taken a very active part. He retained no recollection whatever of what occurred between the beginning of the attack and the moment he recovered himself. Now had this patient quarrelled with and killed a man in the streets, would a magistrate have believed that an individual who, five minutes before and five minutes after, was remarkably intelligent, and who, during this pretended nervous seizure, seemed to have his free will, could commit murder under the influence of an irresistible impulse ? Every physician who has studied epileptic vertigo practically must have seen cases of individuals speaking and answering questions during the attack ; speaking, it is true, in a strange, jerked voice, but still answering questions to the point. The paroxysm once over, they have no recollection of what has just passed. I had a motive, gentlemen, for going into all these details, and you will soon see that they are the key to the solution of the question. I showed you by numerous instances in point that sudden and irresistible impulses are of usual occurrence after an attack of petit-mal, and pretty frequent after a regular convulsive fit. I stated that the patients should not be held responsible for their acts, whether these be followed or not by grave and painful consequences, the gravity of the act itself having nothing to do with the question. The individual is not a free agent for the time, and is, there- fore, free from guilt. This is the first point. The next is, that the epileptic acts unconsciously and without retaining any recollection of what he has done. The very reverse obtains in the case of an insane individual, who is prompted to his acts, it is true, by hallucinations or by motives connected with his delirium, but who still acts with a very determined will, after long and matured premeditation. He always knows what he has done, and is, therefore, conscious of his act; for if he commits the crime suddenly, and sometimes from an irresistible impulse, he does so, in most cases, under the influence of hallucinations which justify the act in his eyes. Whenever delirium supervenes in the course of an acute disease, whenever it consti- tutes what is, by common consent, termed insanity, or follows chronic pois- oning by alcoholic drinks, or is the consequence of repeated attacks of epilepsy which lead to dementia, the acts prompted by it are voluntary, methodical, and the patients always remember them. I admit that the acts of an individual poisoned by alcohol, belladonna, or hashish, may be unpremeditated and committed under the influence of an irresistible impulse, and that all recollection of them may be completely lost, as in the case of an epileptic. I admit that an idiot, whose intelligence and moral sense do not rise to the level of those of the lower animals, may kill a man as he breaks a piece of wood, without being conscious of his act, or keeping any recollection of it. But I never meant to include these par- ticular cases in the general proposition I laid down, since I supposed a com- plete integrity of the reason immediately before and soon after the perpe- tration of the criminal act. That proposition I maintain, therefore, and I do not see that the argu- ments opposed to it in the discussion at the Academy of Medicine have as yet refuted it. I dare not here, I confess, raise the question of irresistible impulses in hysterical and in pregnant women. On that point I deny and I affirm nothing, but remain very incredulous. AND ITS RELATIONS TO EPILEPSY AND ECLAMPSIA. 733 § 2. Apart from Epilepsy, a great many cases of so-called Cerebral Conges- tion, in what is popularly known as the Coup de Sang (ictus sanguinis'), belong to the class of Internal Convulsions, of Vertigo occurring in con- nection with disease of the Internal Ear, and with Dyspepsia.- What happens in the Brain in these attacks is much more nearly allied to Syn- cope than to Congestion.-The Apoplectic Stupor of Cerebral Hemorrhage, of Epilepsy and Eclampsia, is due to what I have called " Cerebral Sur- prise."-Epilepsy and Eclampsia present remarkable analogies.-The condition of the Cerebro-spinal Axis, of which they are both an expression (a condition unknoicn in its essence), suffices for producing Stupor.-The Cerebral Congestion, which in attacks of Epilepsy and Eclampsia may be pushed as far as Hemorrhage, is a Secondary Phenomenon. But let us return to cerebral congestion. One reason why epilepsy is often unrecognized, is the repugnance felt by families to confide the sad complaint even to the physician. A mother may have witnessed a regular convulsive fit, and yet is unwilling to believe in epilepsy. When questioned by the physician, she will mention the loss of consciousness, the coma, but will often omit the convulsions. She will ask for remedies against the acci- dents which follow the attack, but will not allow the truth to be suspected. I have often been consulted by persons who were perfectly well aware that they were afflicted with epilepsy, but who only spoke of congestion. Wives conceal the nature of their husbands' complaint; husbands, of their wives' affliction; and in most cases parents hide the symptoms presented by their children. The physician is therefore constantly deceived in cases of epilepsy; de- ceived by the patient, who knows nothing of his attack, except that he lost his senses, and remained several hours in a state of semi-stupidity; and he is deceived by the parents, who are with difficulty persuaded to confess that a member of their family is an epileptic. He is misled also by what he was taught when a student, namely, that apoplectiform cerebral congestion is a common complaint. There need be no surprise, then, that congestion is so generally accepted. Medical men themselves are often the authors or ac- complices of these mistakes. One of my best friends was an epileptic. As the disease was hereditary in his family, his wife dreaded lest her only son should come in for the sad legacy, and the name alone of epilepsy inspired her with intense terror. When I first found out the painful truth, I confess I had not the courage to tell her of it. I spoke of cerebral congestion, and I succeeded in persuading herself, as well as her son and her intimate friends, that epilepsy had nothing to do with the terrible complaint he was suffering from. A few years ago, under similar circumstances, I wilfully committed the same error. A young lady, belonging to a family I knew intimately, had married a gentleman of good standing. A year after her marriage, she told me that she had fainted in the night, had passed her urine involun- tarily, and had bitten her tongue. The next morning she had felt general lassitude, and had a violent headache on waking. Fortunately she did not sleep in the same bedroom with her husband. I confess that I had not the courage to tell her or her friends the awful truth. For several years the fits recurred during the night only, and in the daytime she had frequent attacks of vertigo. Whilst staying at the seaside, she was one day on the beach, bathing one of her children in less than two feet of water, when she was seized with a fit, and was drowned in less than two minutes. The news- 734 ON APOPLECTIFORM CEREBRAL CONGESTION, papers spoke of it as of death caused by cerebral congestion, and I did noth- ing to correct the mistake. There is, I admit, one form of convulsive epilepsy which may simulate cerebral congestion. In some cases, but very rarely, at the beginning of a fit, in the tonic stage, when the muscles of the chest are perfectly rigid, it happens that instead of lasting only from fifteen to thirty seconds, this tonic condition extends over two or three minutes, and the patients die of asphyxia, in the same way as patients afflicted with tetanus die in a par- oxysm, or animals poisoned by strychnine, as so well shown by Segalas. In such cases there occur no cl on io convulsions, with which persons not be- longing to the profession are most familiar. All the time the tonic condi- tion lasts, the face is swollen, the bloodvessels of the neck look distended, almost knotty, and there is in reality intense congestion, but of a passive character, analogous to what takes place during an effort. Active conges- tion is, however, diagnosed, although there has been, after all, an attack of epilepsy or of eclampsia. Physicians who devote themselves specially to diseases of parturient women and of infants will no doubt remember such cases, and will probably share my opinion. My regretted friend Dr. Meniere, physician to the Deaf and Dumb In- stitution of Paris, had long ago observed a good many cases in which an individual seized suddenly with vertigo, nausea, and vomiting, after walk- ing as if he were intoxicated, fell down, got up with difficulty, and re- mained for a time pale, bathed in cold perspiration, almost in a state of syncope. Ou similar attacks recurring frequently, they were at first re- garded as due to cerebral congestion, and were actively treated with bleed- ing, leeches, and purgatives; but their frequency by degrees compelled a modification of the diagnosis, and excited considerable anxiety in the patient. In the immense majority of cases, individuals so afflicted soon complained of tinnitus aurium, and even of hardness of hearing, for which they con- sulted Dr. Meniere. One or both ears were then found singularly affected, and Dr. Meniere was enabled to collect hundreds of cases showing that these pretended cerebral lesions were in reality affections of the auditory apparatus. He investigated this point with extreme care, and succeeded in finding out that the internal ear was the starting-point of the phenomena in question, and that disease of the semicircular canals was the cause of the vertigo, the sympathetic vomiting, the paralysis of the limbs, and the sud- den loss of consciousness. Vertigo, connected with gastric disorders, is another complaint constantly mistaken for cerebral congestion. This strange form of neurosis is charac- terized by the following symptoms: On the patient moving suddenly in bed, he feels the bed turn and carry him round with it; if he gets up, and particularly, if he then looks up, the giddiness becomes much greater. He sees everything turn round, he staggers, and is sometimes unable to remain standing, whilst he has all the time unbearable sensations of nausea, and is very often actually sick. These curious symptoms are attributed to a rush of blood to the head, and, let us confess it, most physicians hold that opinion. They bleed their patients, therefore, they cup and leech them, and prescribe mustard foot- baths, doing, in a word, all in their power to remove the pretended conges- tion, which their strange treatment merely aggravates. These attacks of vertigo are more allied to syncope, and are consequently the reverse of congestion. However incredible this may appear, it is no less true that too many physicians still fail in recognizing the tendency to syncope, and confound it with cerebral congestion. AND ITS RELATIONS TO EPILEPSY AND ECLAMPSIA. 735 There is a symptom, however, which often accompanies cerebral hemor- rhage, and which by all medical men is regarded as indicative of conges- tion. Thus a man, in whom cerebral hemorrhage takes place, sometimes be- comes suddenly insensible, and this abolition of the intelligence and of the power of motion lasts from a few hours to several days. He theh comes round again, with the exception of a trifling degree of hemiplegia, which slowly diminishes and finally passes off, after a period varying from a few weeks to several months. As the first symptoms set in almost with the rapidity of lightning, and as there seems to be no proportion between their gravity and the subsequent impairment of the intellectual faculties and the power of motion and sensation, it is said that the cerebral hemorrhage has been attended with congestion, and that the congestion, an essentially transient phenomenon, has caused the apoplectic symptoms proper, and on disappearing, has left behind it hemorrhage to a small amount, and trifling paralysis. I do not mean absolutely to deny the existence of this conges- tion, and I even confess that I am inclined to admit it within a certain limitation. There is, however, another symptom to which sufficient im- portance has not been attached, so far as I know,-namely, a kind of stupor, like what follows on commotion, and to which I have given the name of cerebral surprise. When the brain is suddenly torn or compressed, it bears such a grave lesion with an impatience which varies according to individuals, but which may be very considerable in some cases. Wounds of the brain give us an illustration of this. When a soldier, for instance, is wounded in the head by a ball, or when a man, in a brawl, is stabbed in the head, and the knife enters the brain, he drops as if knocked down by a blow from a stick ; but by degrees, notwithstanding the intracranial effu- sions of blood, which are a consequence of the wround, and even notwith- standing the inflammatory congestion inseparable from a laceration of the tissues, the intellectual faculties, the power of motion and sensation, are sometimes recovered with extraordinary rapidity, and thus give the inex- perienced surgeon hopes which are unfortunately never realized. What I have called cerebral surprise is this instantaneous stupor. However incor- rect the term I use may be (and I would gladly give it up), the fact exists and cannot be denied. Experiments on the lower animals give still more positive results. Tf, after trephining the skull of a dog or a rabbit, a small leaden ball be intro- duced, through an aperture in the dura mater, between the skull and the surface of the brain, symptoms of stupor are immediately manifested, which gradually pass off* and are succeeded by an amount of hemiplegia propor- tionate to the compression. In this experiment no cerebral congestion can be appealed to, and it must be admitted that the brain is somehow surprised by an accident which is accompanied by a transient disturbance. Am I not authorized, then, to suppose that when blood is suddenly effused into the corpus striatum or the thalamus opticus, the immediate stupor which is ordinarily attributed to a simultaneous congestion can, in part at least, be due to cerebral sur- prise ? Does it follow, gentlemen, that I absolutely deny the existence of cerebral congestion ? No, indeed; I admit cerebral hyperaemia, for I should be insane if I were to deny it; but I maintain that what has been called apoplectiform cerebral congestion is, in the greater number of instances, a symptom of epilepsy or eclampsia, and, in some cases, of syncope. I main- tain that very often simple epileptic vertigo, and vertigo connected with a disordered state of the stomach or with diseases of the internal ear, are wrongly looked upon as cases of cerebral congestion. 736 ON APOPLECTIFORM CEREBRAL CONGESTION, If the propositions which I have attempted to prove be true, it will be conceded to me that we must less frequently have recourse to revulsives and to antiphlogistic measures in our treatment of these cases of pretended cere- bral congestion, and that we must seek for other indications more in con- formity with the views that should be entertained of the various conditions too often confounded under the same denomination. You remember, gen- tlemen, what stormy discussions were excited, in the beginning of the year 1861, by the opinions I now express, and which I then communicated to the Academy of Medicine (" Bulletins de 1'Academic de Medecine," Paris, 1861, t. xxvi). I neither pretended that I had discovered something, nor did I mean to teach my colleagues that attacks of epilepsy and eclampsia were followed by apoplectic phenomena; this had been said at all times and by every one. I only stated and attempted to prove a fact seen and recognized by some physicians ; namely, that sudden apoplectic seizures were oftener than is generally believed, connected with a fit of epilepsy or eclampsia. I spoke, indeed, of transient apoplectic phenomena occurring in an individual enjoy- ing excellent health, with or without the premonitory symptoms which pre- cede an attack of grand-mal, and leaving him, shortly afterwards, in the same state as before the seizure. To speak unreservedly, gentlemen, I must at once declare that, in my opinion, epilepsy and eclampsia are two identical neuroses, with regard to their symptomatic expression and their proximate cause. When treating of epilepsy, I will show you that an attack of eclampsia is exactly like one of epilepsy, and that no physician will ever be able to distinguish between convulsions occurring in a pregnant woman, long afflicted with epilepsy, and convulsions in a woman seized with eclampsia, at the beginning of labor. So much for the symptoms. Now, as to the proximate cause, I believe it to be identical in both affections. When epilepsy manifests itself by monthly attacks in an individual with a tubercular deposit in his brain, there are in the brain and spinal cord, apart from the deposit of tubercle, no appreciable lesions other than those which exist in the so-called idio- pathic epilepsy. On dissection, if we find a deposit of tubercle, a cancer, or a bony tumor, the rest of the brain presents merely the appearances of vascular congestion, met with in the case of a true epileptic who has died in a fit. What inference must we draw from this ? It is this, that if the tumor in the brain be the cause of the convulsions, it is not the proximate cause ; this does now, and will probably, always escape us. Eclampsia occurring in a child who is cutting his teeth or has worms, or is suffering from scarlatinal dropsy, does not in the least differ as to the convulsions from an epileptic fit, and yet these two affections are widely distinct as to their nature. I mean to say that the molecular condition of the brain and spinal cord is, perhaps, the same in both cases. Allow me to explain myself. When we see an individual who for twenty years has been subject to almost periodical fits, and yet manifests no signs of insanity or general paralysis, we say that he is suffering from idiopathic epilepsy. If in the intervals between the attacks there be hemiplegia, violent headache, or exclusively nocturnal pain, we suspect the epilepsy to be symptomatic of a tumor in the brain, or of tertiary syphilis. If the convulsive disorder occurs in a pregnant woman with albuminu- ria, or in an individual with scarlatinal dropsy, or suffering from lead- poisoning, we call it eclampsia. We give the same name to the convulsions which, in children, so fre- AND ITS RELATIONS TO EPILEPSY AND ECLAMPSIA. 737 quently announce the invasion of febrile exanthemata,-of variola, for instance,-and to those which supervene at the close of cerebro-meningitis, or what is termed cerebral fever. If the epileptiform convulsion takes place in an individual who has just been bled, or in an animal who is left to die of hemorrhage ; or, again, if it occurs, as in that curious experiment of Brown-Sequard, after the section of a lateral half of the spinal cord, under the influence of certain kinds of external irritation,-we also call it eclampsia. What is the relation, then, of eclampsia to epilepsy, and of epilepsy to eclampsia? If we look at the convulsive character alone of the two affections, sympto- matic or idiopathic epilepsy, to use the bad divisions generally accepted, is only recurring eclampsia, and eclampsia is merely accidental and transitory epilepsy. Eclampsia has been said to differ from epilepsy in the continuity and the occasionally prolonged duration of the convulsions which it causes; but although there be some truth in this distinction, there yet occur cases of eclampsia in which there is but a single attack, and cases of epilepsy with continuous seizures. Now, for an organicist,-and I confess that I am one, in this sense at least, that I do not conceive a functional lesion without a modification of the organ which discharges the function,-every case of epilepsy or of eclampsia must be symptomatic, either of a tumor, or of some form of poison- ing, or of a peculiar state of the blood, or of some inappreciable organic condition, as happens in epilepsy proper, in eclampsia from worms, or eclampsia which follows on venesection or hemorrhage to a large amount. In medical language (which I do not defend, and which I only use from want of another, and in order to be better understood) we accept the name of eclampsia for convulsions occurring in the course of the cerebral fever of children; and why should we refuse to give the same name to convulsions due to chronic cerebro-meningitis, which according to Royer-Collard, Cal- med, and many others, causes the general paralysis of the insane? We give the name of symptomatic epilepsy to convulsions which are caused by worms, or which are due to tubercle or cancer of the brain; and why should we refuse the same appellation to the convulsions which occur at the onset of tubercular meningitis? Let us be logical, therefore, and let us admit that all epileptiform con- vulsions, although depending on very variable causes, are apparently the expression of the same intimate modification. If we admit this, we shall better understand the relation of eclampsia and epilepsy to what is, by common consent, called apoplectiform cerebral congestion. As I shall tell you by and by, during the tonic period of an epileptiform seizure, the glottis is closed, and the patient makes a supreme effort, during which the face, the vessels of the neck, and necessarily those of the brain, get congested. The cerebral congestion may in such cases, then, be con- sidered as secondary and passive. But is the profound bewilderment, gentlemen, which succeeds an attack of eclampsia or epilepsy merely an effect of this passive congestion ? I con- fess that I do not believe it; for the sudden loss of consciousness which occurs at the beginning of an epileptic fit, and which is from the first accom- panied by a deadly pallor,-as so well pointed out by Calmeil, in his excel- lent thesis on epilepsy,-is the sign of such a deep modification in the functions of the brain, and perhaps in its intimate structure, that the stupor sequential to the attack is more probably a result of this modification than of the secondary passive congestion. vol. i.-47 738 ON APOPLECTIFORM CEREBRAL CONGESTION, Mark, indeed, that we cannot admit, as many physicians do, that the attack of eclampsia is the consequence of a primary congestion, when, on the one hand, we see that the severity of the fit is by no means proportion- ate to the degree of previous plethora, and that, on the other hand, epilep- tiform seizures which follow on a considerable loss of blood are as severe as those noticed under perfectly different circumstances. Add to this-as you will read in the Journal de Physiologic of Dr. Brown-Sequard-that, at the onset of an epileptic fit, the great nervous centres and the medulla oblongata of an animal subjected to experiment become paler, instead of presenting signs of congestion. Hence it follows, that what we all call apoplectiform cerebral congestion, and the apoplectic phenomena which succeed epilepsy or eclampsia, may be nothing more than a condition analogous to the apoplectic stupor which immediately follows on some severe cerebral disturbance, and which cer- tainly occurs independently of all congestion. Some think it very natural that cerebral congestion should produce such grave phenomena. But see what occurs in a woman during labor. As the child's head is going to pass the inferior outlet of the pelvis and the external organs of generation, the woman often makes most violent efforts. Her face becomes blue, her lips and eyelids swell, her skin gets hot and bathed in perspiration, and there can be no doubt but that the sinuses of the dura mater, and the whole sub- stance of the brain share in this congestion. Is it under such circumstances that women are seized with eclampsia? Ask accoucheurs, and they will tell you that eclampsia manifests itself often before all signs of labor have shown themselves, and, in most cases, when there have scarcely been slight uterine contractions, which do not even attract the notice of the patient. There was, it is true, albumen in the urine; but what has albuminous urine to do with convulsions, when a rational explanation is sought for? It seems that in such cases convulsions are excited by a sympathetic cause as slight as the scarcely-perceived sensations which arise from the presence of worms in the intestines. Children affected with hooping-cough may have so many fits of cough- ing in rapid succession, that an intense degree of congestion is thereby brought on; so much so, indeed, that they may have hemorrhage from the nose, that their face will remain persistently puffy, and ecchymoses will in some cases form beneath the eyelids. There can be no doubt about the brain participating in the congestion. The fit over, they remain for a while in a state of bewilderment; but can this be compared with the light- ning-like suddenness of an attack of eclampsia, and the apoplectic phe- nomena which follow it? Acrobats, who go through many of their performances with their head downwards, never suffer from anything like apoplectic stupor. The por- ters of the Halle, who all day long carry heavy burdens, and who, con- stantly making powerful efforts, get almost blue in the face, whilst the bloodvessels of the neck are turgid, and look like knotted cords, are never seized with sudden loss of consciousness or of muscular power, at the very moment when they are exerting themselves the most. Let us admit, then, that so long as the blood is not altered in its inti- mate composition, and is not extravasated, it is not so injurious to our tis- sues as is commonly said ; and that something more than a purely physical congestion is needed to produce the apoplectic phenomena which succeed epilepsy or eclampsia. I understand better the disturbance which follows on that special and essentially vital molecular condition which is termed flux or inflammation. There are, therefore, and I lay great stress on the point, two very distinct AND ITS RELATIONS TO EPILEPSY AND ECLAMPSIA. 739 conditions in an attack of eclampsia, or of epilepsy, whether idiopathic or symptomatic: 1st. A cerebrospinal modification, unknown in its essence and in its nature, which in a second abolishes all the manifestations of animal life. Of the two, this is by far the more important condition. 2d. A secondary cerebral congestion, which, although less important, may in some extremely rare cases be carried so far as to produce subcutaneous ecchymoses, cerebral capillary hemorrhage, and even meningeal hemor- rhage. Apoplectiform cerebral congestion is a term which has, in my opinion, been wrongly applied to the state of stupor which succeeds the complicated dis- orders I have just alluded to ; and this term has had an injurious influence on the treatment employed, and on the notion medical men have formed of the disease. Without quarrelling about names, and about the ultimate alterations which characterize what physicians call apoplectiform cerebral congestion, there can be no difference of opinion concerning the phenomenon itself. It is a state of profound stupor, analogous to that noticed in cases of indi- viduals struck down by apoplexy, and it is attended with apoplectic phe- nomena ; its cause being in a great number of cases epilepsy, idiopathic or symptomatic, or eclampsia. These explanations were necessary before I could lay down the following proposition: The same cerebrospinal modification which causes the fit of epilepsy or eclampsia, the insulins, the ictus epilepticus, is sufficient to produce the apoplectic stupor which follows it. In a child suffering from cerebral fever, there doubtless is some stupor, but never to a considerable degree. Let an attack of eclampsia supervene, however, and in a minute, from a state of scarcely appreciable stupor, he gets into an apoplectic condition. What applies to the acute cerebro-meningitis of children applies also to the general paralysis of the insane, which is probably nothing more, after all, than a symptom of chronic cerebro-meningitis. In the latter case, with the exception of delirium, and of some uncertainty in his speech and gait, which do not escape those familiar with the diseases of the insane, the patient apparently enjoys good health ; but on his having an epileptiform seizure, he is .struck down instantly, and passes into an apoplectic condition. In neither case is the cerebro-meningeal inflammation the proximate cause of the convulsive and apoplectic attack; it is only an indirect cause, the immediate one being the minute central modification which brought on the attack. Hence it follows that the apoplectic condition so often observed in the course of the paralysis of the insane is dependent on eclampsia, just as the analogous which follows an epileptic fit is dependent on epilepsy. Let us pause awhile, gentlemen, and ascertain how far we have got on with the discussion. I have proved that transitory apoplectic phenomena occurring in an individual in good health, and leaving him in the same condition after as before the attack, were, in almost every case, associated with epilepsy or eclampsia. I have just shown that in cases of acute or chronic inflammation of the brain, and even in cases where the nervous symptoms arise merely from sympathy, as in typhoid fever, and in pneumonia, for instance, sudden apo- plectic phenomena were almost always preceded by epileptiform convulsive phenomena. I can therefore repeat what I stated just now, namely, that the same modification of the nervous centres which produces the convul- sions, is sufficient to account for the apoplectic stupor, and that the pre- 740 ON APOPLECTIFORM CEREBRAL CONGESTION. existing inflammatory congestion is by no means the cause of the new symp- toms that set in suddenly. I am accused of making light of cerebral congestion, and of too easily doing away with it in Nosology. This is far from true, gentlemen, for I do not deny the existence of cerebral congestion, but only of that congestion which is said to produce sudden and transient apoplectiform phenomena. I admit determination of blood to the brain, as to any other organ, from irri- tation or inflammation. I admit that congestion evidently accompanies it, and that it is sometimes carried to such a degree that symptoms of apo- plexy may be produced ; but those symptoms are neither sudden nor tran- sitory. Again I repeat, I only meant to speak of sudden and passing apoplectic phenomena, and, as far as they are concerned, I maintain my first opinion. If I make light of cerebral congestion, and refuse to see it where others do, you will agree with me that it was formerly, and is still, too lightly accepted. Hemicrania and simple headache are said to be due to cerebral conges- tion. The stupor of typhoid fever, of typhus, pneumonia, the plague, va- riola, scarlatina, is set down to the account of congestion; and so is the de- lirium of pneumonia, of hysteria, St. Vitus's dance, erysipelas, &c. Sleep itself has by some physiologists and physicians been ascribed to cerebral congestion. Therefore, whenever stupor and drowsiness showed themselves, whenever delirium or a tendency to dreaming set in, cerebral congestion was admitted with a facility which now appears strange to most practitioners. Nobody knows what sleep is; and the resemblance between two individuals, one of whom is plunged in a deep sleep after great fatigue, and the other after an attack of apoplexy, has probably led medical men to attribute to one and the same cause conditions which have but a decep- tive resemblance. This singular opinion, however, which was not based on experiments, has strangely influenced the notion formed of the action of poisons. If opium induced sleep, it was by causing cerebral congestion. Solana- ceous plants, ranunculus, colchicum, digitalis, prussic acid, &c., caused stupor, because they induced cerebral congestion. The same obtained with viruses and with animal poisons, whether wholly produced in the living or- ganism, in the course of toxsemic diseases, or whether introduced from with- out. Profound stupor was always ascribed to congestion. I have already said how innocuous I believed congestion to be; besides there is no need whatever to have recourse to congestion in order to explain the action of poisons. They are absorbed and circulate in the blood, and, therefore, come in contact with all parts of the system, disturbing them more or less completely, independently of the liquid which acts as their vehicle; and often, as shown by the experiments of Magendie, in an inverse ratio to the amount of blood accumulated in the brain, for example. Excuse me, gentlemen, for having dwelt so long on this point. The opinion I expressed before you at the beginning of this conference seemed extraordinary at first, but I am sure that it no longer seems so to you now, and that you are convinced, as I am myself, that Midden and transient symp- toms of apoplexy are in most cases associated with epilepsy or eclampsia. ON EPILEPSY. 741 LECTURE XLI. ON EPILEPSY. Cases of Epilepsy.-Description of a Fit.-How to recognize the Feigned Dis- ease.- Three stages: Tonic Convulsions, Clonic Convulsions, and Stupor. -Synonyms: Morbus Major, Morbus Comitialis, Morbus Herculeus, Fall- ing Sickness, Haut-mal, &c., &c.-Sequelae: Subcutaneous Ecchymoses, Cerebral Hemorrhages, &c.- Cerebral and Spinal Lesions are Effects, not a Cause of Epilepsy.-Exciting Causes.-Status Epilepticus.- Petit-mal. Gentlemen : We have lately had in our clinical wards several patients afflicted with epilepsy. One of them was a young man, aged 18, who occu- pied bed 18 in St. Agnes Ward, and presented that peculiar form of the disease which has been called partial epilepsy. It consisted, in his case, of convulsions of the facial muscles, exclusively limited to the left side, and unaccompanied by any phenomenon usually met with in an attack of haut- mal, or by loss of consciousness. On inquiring into his previous history, we learnt that the disease first set in about six years ago, with attacks of haut-mal. These were very violent at the commencement, but gradually became less so, and although there occurred convulsions from time to time, he generally suffered from epileptic vertigo only. Before proceeding further, let me call your attention to this transforma- tion of epilepsy, a fact pointed out long ago by the practitioners who spe- cially investigated the question; by Calmeil among others. Let me remark, however, that they spoke of the transformation of petit-mal into grand-mal, whilst in the case of our patient, the reverse, occurred, the convulsions having preceded the vertigo. You may remember, also, another of our patients, an American, who, after having tried the public institutions of his native country, obtained admission into different Paris hospitals, and finally went to, and, as I have been told, died in London. He was tall and powerfully made, and had been nicknamed the blue man, because of the slate-blue discoloration of his skin, due to a prolonged treatment with nitrate of silver, to which he had been subjected in the United States. You saw him in several of his fits. On a sudden, he shrieked out, strug- gled, and turned round on his own axis, catching hold of the bedstead when he could, and losing consciousness entirely. The fit lasted a few seconds, after which the poor fellow recovered himself, although for several hours afterwards he remained in a state of bewilderment, and almost stupefied. You remember the fixed idea he had: he had heard that castration had been performed for the cure of epilepsy, and not a day passed but he begged to be operated on. It was only after he became convinced of our determi- nation not to accede to his request, that he left the hospital, and soon after- wards quitted France. About the same period I had a third patient in bed 20, St. Agnes Ward, whose history deserves to be related in detail. He was 36 years old, and had specially comfe from Bouconville (in the department of Ardennes) to be treated in Paris. 742 ON EPILEPSY. He had the aspect of a man of a robust constitution, and he stated that, indeed, he had never been ill. For four years and a half he had served, as a marine in Guadaloupe, and had enjoyed excellent health there. The only ailment he ever had was chronic coryza, dating many years back, and which ceased suddenly at the time when he first became subject to attacks of haut-mal. This coincidence led him to ascribe his disease to the sudden disappearance of the coryza. He affirmed that he had never been addicted to spirituous liquors. None of his relatives, direct or collateral, had ever suffered from nervous disorders; and his own child, then four years old, was in excellent health, and had never had convulsions. The disease dated five years back. One night he had been suddenly awakened and frightened by horrible shrieks from his wife, and a few days afterwards he had his first attack. In the beginning, these seizures were characterized by a sensation of inward cold, of rigors, and, to use his own words, of trembling, seated some- times in the arms, the legs, or thighs, and sometimes in the pit of the stom- ach, or various parts of the body. This sensation spread all over him, and lasted a few minutes, without being attended with loss of consciousness. The attacks recurred at irregular intervals, rarely longer than four or five days, and were brought on by the slightest painful emotion, the least varia- tion of temperature, a draught of cold air, or exposure to a hot sun. They gradually increased in severity, and within the last few months had become considerably more frequent and violent. They were now regular convul- sive seizures, similar to those he had on admission, and several of which we witnessed ourselves. On the day of his admission, he had just lain down, when he suddenly got up, taking hold of the bar across his tester-bed, then throwing his arms about, began to vociferate in the most atrocious manner. His face was of a purple-red color, his looks haggard, his voice loud, and his articulation rapid. He looked exactly like a delirious maniac. The attack had set in with quivering of the legs, followed by convulsions. He was so wildly delirious, that he frightened the patients in the ward. He had rushed out of bed, and had to be confined in bed with a strait-waist- coat. He was perfectly unconscious of his acts, and kept insulting those who were attending him. This fit lasted about twenty minutes, and with- out any transition he became calm. He spoke distinctly, and begged to be unloosed, as he felt the fit was over. I shall again call your attention presently to these phenomena of furor, and I will point out to you their medico-legal importance in determining the degree of moral liberty enjoyed by some persons, who, without any motive, have suddenly committed acts of violence, and even murder. On the day following, the patient related to us his previous history, add- ing that within the last few months only had his fits been accompanied with loss of consciousness. Once his wife, on returning home, was sur- prised to find blood on the floor of the room; he was astonished himself, and on putting his hand to his head he felt a wound which he had re- ceived on falling down during a fit, of which he had no recollection. His fits were generally preceded by the sensations I have already de- scribed ; he next lost consciousness, was convulsed, and immediately be- came delirious. The attack lasted from twenty minutes to an hour even. He then became calm again, but complained of general lassitude, and usually of headache, which he compared to the compression that would be produced by a circle of iron. He was oftener seized at night than in the daytime. Of late his memory had seemed to fail; sometimes he felt con- fused and had a difficulty in collecting and in expressing his thoughts. He had become impotent also. ON EPILEPSY. 743 During his stay in the ward I had an opportunity of having him watched carefully, and of observing myself what happened during his fits. They never occurred in the same way. Once he was seized when walking out in the garden, and a companion who was with him thus related the circum- stances : He turned pale suddenly, in the midst of a conversation, looking hag- gard, with his teeth chattering and his arms moving about in a disorderly manner. He was made to sit down on a bench, and his face then growing red, he laid hold of his companion's coat, as if he wished to strip him, and when asked what he meant to do, answered that his companion ought to take it off. He spoke distinctly, and yet he was so restless that he could with difficulty be kept on his seat. This attack lasted ten minutes, and was followed by a condition of bewilderment and perfect stupidity. When made to go up to the ward, he offered no resistance, his gait resembling that of a man under the influence of liquor. On recovering himself, he remembered nothing of what had occurred. On another occasion, I had just been talking to him. He was sitting on a chair at the foot of his bed, when I suddenly saw him beating the ground with his feet. His face was excessively pale, his features distorted, his look haggard. He kept nervously looking about everywhere, under his sheets and under his own clothes, exclaiming, " Where is it? ... . my spoon ?" I vainly tried to question him ; he made no answer, and seemed unconscious of all that passed around him. He yet pushed away my hand when I touched him. This time he had no convulsions. The fit lasted two or three minutes, and left him in a state of prostration. These cases, gentlemen, may have appeared very singular and excep- tional to some among you, but they are met with pretty frequently, how- ever. I must therefore call your attention particularly to them. In all these three cases, as in others you have also seen in my ward, epilepsy was the disease under which the patients labored. This is a very important subject, and I intend to investigate it with you. By pointing out to you the various forms which it assumes, I will try and enable you to recognize this disease, one of the most formidable which afflict mankind, by means of imperfectly developed, nay apparently, insignificant symptoms. The term epilepsy conveys to non-professional persons, and we must con- fess it, to many medical men also, the notion of a disease characterized by convulsive attacks, generally of short duration, and attended with loss of consciousness, swelling of the face, distortion of the mouth and eyes, im- mobility of the pupils, and a good deal of foam at the mouth, tinged red with blood. Such, in fact, is the definition, very imperfect though it be, of an epi- leptic fit. But this is only one of the forms of epilepsy, and there are many others besides, which are perhaps more frequently met with, and which, however different they may appear at first sight, present the greatest analogies be- tween one another. And I hope to be able to prove to you that they are, after all, the expression of one and the same disease. The convulsive form itself is often mistaken, or rather confounded with other convulsive affections, such as hysteria, and particularly the various kinds of eclampsia. These latter, it is true, simulate epilepsy very closely, but are nevertheless perfectly distinct affections. But first, how are you to recognize real from feigned epilepsy ? Thus army doctors will tell you that individuals often feign epilepsy in order to be exempted from military service. But the real disease is char- 744 ON EPILEPSY. acterized by certain phenomena which do not escape the observation of an experienced practitioner, and could only be feigned by individuals thor- oughly familiar with them. Esquirol, however, believed that even such per- sons could not perfectly imitate the disease. Yet he was deceived himself, and on this occasion : One day, Dr. Calmeil and I were talking with him on this very subject at the Asylum of Charenton, when suddenly Dr. Calmeil fell down on the floor in violent convulsions. After examining him for a moment, Esquirol turned round to me, exclaiming, "Poor fellow, he is epileptic I" But he had no sooner said so than Dr. Calmeil got up and asked him whether he still persisted in thinking that epilepsy could not be feigned. Although Esquirol made a mistake in this case, I still maintain his proposition, and I believe that even a physician, thoroughly familiar with all that takes place during a fit, will only imitate it imper- fectly, because there are some phenomena which cannot be produced at will, as I will show you as I proceed. Now let us see what usually happens during a fit. All of a sudden, without any premonitory symptom, the patient utters a loud scream, and falls usually on his face. This is already an important fact, and characteristic of the real disease. A man who feigns epilepsy takes good care not to throw himself down in that way, or if he does so, he keeps his hands in front of him, in order to protect himself on falling. The true epileptic is thrown down with such violence, that his head knocks against any obstacle in the way. Sometimes he falls backwards, or on one flank, but in most cases, I repeat, he falls forwards, and it is, therefore, on his nose principally, his forehead, his chin, his cheeks-in a word, on the prominent portions of his face, that you will find either actual wounds or scars of old ones. Fractures of the skull, or of the bones of the extremities, dislocations, may also be caused by the fall. In some cases the patient falls into the fire and burns himself fearfully ; instances even have occurred of persons found burnt to death, after falling into the fire, and whose faces were so charred as to be no longer recognizable. When down on the floor, the patient presents symptoms which should be carefully studied, because, although they do not last long, they are yet very characteristic. As he falls down, the epileptic is not red, as it has been wrongly stated, but deadly pale; and this is another phenomenon which is necessarily absent in feigned epilepsy. Convulsions then begin immediately. They are tonic at first, consisting in a powerful contraction of the muscles, which are in a state of violent tension, without alternate relaxation. They are more marked on one side than on the other, a char- acter of great value in an epileptic fit, because rarely absent. Sometimes even they are limited exclusively to one half of the body. You will see, for instance, one arm twisted on itself and drawn backwards, the hand flexed, the thumb forcibly adducted and hidden by the fingers, which are bent over it into the palm. The lower extremity is also convulsed: the foot is arched and extremely tense : the leg is forcibly extended and twisted on itself. The muscular rigidity is not to be overcome, and although they contract convulsively with a certain degee of slowness, the muscles are agitated by quivering of their fibrillae, which can be easily felt. To the hand they feel as hard as iron. The twisting and forcible pro- nation of the limbs are so violent, that injuries may result; and I recently saw a case of spontaneous dislocation of the shoulder, which had not oc- curred at the time of falling. Such injuries may even be inflicted in nocturnal attacks, occurring during sleep, and I shall by and by dwell on their significance, as regards diag- nosis.. The following is an instance in point: ON EPILEPSY. 745 At the end of the year 1862 I was consulted by a gentleman, aged 50, who told me that he awoke one morning complaining of a sense of fatigue and of pain in the right shoulder, which was so acute as to completely pre- vent him from moving his arm. He had formerly suffered from acute articular rheumatism, and the medical man whom he sent for, after exam- ining the painful joint, came to the same conclusion as himself, namely, that it was affected with rheumatism. The pain in the joint and its ex- treme rigidity persisting, however, without abatement, the patient, after several months had elapsed, returned to Paris, and consulted Mr. Maison- neuve, who recognized a dislocation, which was reduced with great difficulty on account of its ancient date. Some time afterwards the same accident occurred again under identical circumstances, but on this occasion the dis- location was immediately reduced. Certainly, gentlemen, no dislocation of the shoulder ever occurs in ordi- nary sleep, and after the patient had related to me what had happened to him on these two occasions, I did not for a moment hesitate to ascribe the dislocation to nocturnal attacks of epilepsy. Other details, told me by the gentleman himself, confirmed my diagnosis. He had, indeed, on several occasions since, suffered from sudden fainting fits, and from vertigo, about the nature of which no doubt could be entertained. Allow me to revert for a moment to the peculiar circumstance that tonic convulsions, in an epileptic fit, are generally more marked on one side, and sometimes even exclusively limited to one half of the body. Those who feign attacks are not aware of this, and think they ought to be convulsed on both sides, although if they knew the circumstance they might imitate it. The muscles of the trunk are affected as well as those of the limbs. The sterno-cleido-mastoid, for instance, is thrown into contraction, and as a consequence, the head of the patient is drawn down to the shoulder on the affected side, and the face turned to the opposite side. This is another circumstance not known to impostors. The muscles of the thorax and abdomen are likewise in a state of tetanic rigidity, and the respiratory movements are completely arrested. The fibrillary quivering I mentioned just now as being felt on laying one's hand on the chest of the epileptic, is no longer perceived. After these tonic contractions have lasted a few seconds, and the thorax remained perfectly motionless, the face then begins to redden, and it is then and then only, and not when the individual falls, that the veins of the neck get distended, and that the face turns livid, re- maining so for a pretty long time. At the time, however, when tonic convulsions affected the muscles of the limbs and trunk, the face was distorted from the convulsions of its muscles. The tongue also, violently thrust forward from the involuntary contraction of the genio-hyo-glossi, protruded through the half-opened jaws, swollen out and purplish, but not yet cut or wounded by the teeth, as it often is in a later stage. In some cases, however, even in this first stage, the tongue is caught between the teeth, and deeply bitten, when the mouth closes slowly, after having been hideously distorted and partially opened. This may be termed the first stage of an epileptic fit, or stage of tonic convulsions. It lasts from ten to forty seconds at most, and the second stage, or that of clonic convulsions, then begins. The limbs are alternately flexed and extended, and it is this stage which characterizes the epileptic fit with which everybody is familiar, and which is easily simulated. It lasts from half a minute to two minutes at the most, so that the whole duration of the attack varies from two to three minutes, and in most cases, still less than this. Those of you who have witnessed epileptic fits may probably think that I limit the time too much, but it is only because three 746 ON EPILEPSY. minutes of such a horrible spectacle as that of a man in a fit seem very- long indeed, and appear to last three or four times longer than they really do. But observations made watch in hand, testify to the correctness of my statement, and indeed Dr. Calmeil has himself pointed the fact out, and laid it down as a general law. The clonic convulsions are more violent on the same side as those of the tonic kind were. They come on at first every second, and sometimes at still shorter intervals. They affect the muscles of the face, as well as those of the limbs and trunk; and from the exaggerated contractions of the muscles of the chest which modify the respiratory movements, breathing becomes jerking and noisy. The convulsive movements describe a gradually larger and larger circle, until at last the muscles are fully stretched out and extended suddenly, when the patient draws a deep sigh, and the fit is over; at least, the con- vulsions are over, for a third stage now begins. In most eases, it is in the second stage that the tongue is wounded: thrust forward through the half-opened jaws by the contraction of its extrinsic muscles, it gets squeezed and bitten by the teeth when the muscles which elevate and depress the lower jaw are thrown into clonic convulsions. The wounds which are thus produced, account for the more or less abun- dant hemorrhage, and the reddened foam noticed in a great many cases. The blood may also come from the nostrils, or be poured out from the gums, which are bruised through the breaking of one or several teeth occurring at the time of the fall, or during the fit itself. With the clonic convulsions ends the convulsive attack proper; but the patient then falls into an apoplectiform condition, and looks like an animal that has been felled, or an individual in whom there has occurred a con- siderable extravasation of blood into the brain, or who is stupefied by drink. His breathing is stertorous, and during expiration his half-opened lips give issue to frothy saliva, which is tinged with blood. For a length of time varying from a few minutes to half an hour, he remains in this con- dition of profound stupor and complete immobility. His intellectual faculties and power of feeling are entirely abolished during and imme- diately after the attack, so that he may be pinched, pricked, or burnt, without being conscious of it. In those cases, which are unfortunately not uncommon, when the patient falls into the fire, he may be burnt in a most awful manner without expressing or feeling the slightest pain. On lifting his upper lid, his pupil may be seen to be dilated, and refuses to contract under the stimulus of the brightest light. He neither hears nor smells, and a bottle of strong ammonia may with impunity be held under his nose. These again are facts which cannot be simulated by impostors. At length the patient opens his eyes: at first he looks around him in a stupid, confused manner. If he be still lying on the ground, he attempts to get up; but his movements resemble those of a drunken man; he looks ashamed, and tries to avoid the observation of lookers-on. If questioned, he falters out a few unintelligible words, and he can scarcely give the sim- plest information concerning himself, such as giving his own name and address, or he even makes no answer at all. He allows himself to be led about, however, to be put inside a carriage and taken home without offer- ing any resistance, but at the same time with as complete an indifference as if he was not conscious of what was going on. For a few hours afterwards, or a day, a couple of days sometimes, he complains of headache, and of some mental confusion, particularly of some failure of memory. Sometimes, also, he remains temporarily paralyzed on ON EPILEPSY. 747 one half of the body. But in general, by the next day, he has recovered his usual condition. This is what is termed an epileptic fit, gentlemen, the grand-malor morbus major of Celsus, which authors have designated by other names, such as morbus sonticus (the fatal disease), morbus lunaticus astralis, so called because the motions of the stars, of the moon in particular, were said to influence the attacks ; morbus caducus (falling sickness) ; morbus comitialis, because if a man were seized with epilepsy during a meeting in the forum, at Rome, the assembly was broken up; morbus hercideus, beracleus, so called because Hercules was said to have been an epileptic; morbus sacer, divus, because sent by the gods ; St. John's complaint, St. Giles's complaint, as it was termed in the Middle Ages, and as it is still called in some departments in the south of France; and again, morbus demoniaeus, at the time when epileptics were believed to be posssessed with the devil. All these names are applied to the convulsive fit, or Aawf-wiaZ, the most striking and the most familiarly known form of epilepsy. But what everybody does not know, and what must be consequently pointed out, is the fact that epileptic seizures very often, in the beginning especially, occur during the night; and that an in- dividual may thus be afflicted for eight or ten years, although nobody, not even himself, suspects the existence of this dreadful disease. Certain phe- nomena, however, and certain accidents, enable one to recognize a past attack: such as contusions, and injuries of a more or less serious nature, inflicted on the patient as he falls down, or caused by the severity of the convulsions, of which he bears traces at least on some part of his body. Dislocations of the lower jaw, of which there are instances on record, and the mechanism of which is plain, dislocations of the shoulder, although rare, but of which I quoted an instance myself, point in the same way. Even apart from these accidents, there are other circumstances more fre- quently met with, and which have, on the whole, an important significance. In the beginning of the year 1863, Drs. Tardieu, Legrand du Saule, and Caffe, were called upon by a court of justice to report on the mental con- dition of a lady whose interdiction was applied for. Their inquiries had for a long time remained fruitless, and although they had ascertained a cer- tain degree of failure of memory, they yet could not call it dementia, and they felt great embarrassment at giving a categorical opinion, when they were informed that the lady sometimes suffered from incontinence of urine, both by day and by night. Now, indeed, was light thrown on the subject, and on questioning the lady more closely it became evident that she fre- quently had nocturnal fits of epilepsy, during which her urine escaped in- voluntarily. Frequently also, in the daytime, she had attacks of giddiness, which lasted a few seconds, and during which her urine escaped involun- tarily. When once epilepsy had been recognized, it was better understood how, under the influence of fits which were not noticed, her reason was sometimes seriously disturbed, Dr. Legrand du Saule, who related the above case at a meeting of the Societe de Medecine Pratique, mentioned also that he had seen, at Contrexe- ville, a young lady who pretty frequently wetted her bed, and whose tongue was wounded in some places from being probably bitten on the same occa- sions. Besides the urine, the motions may be passed involuntarily, and the in- dividual finds himself in a mess, on waking up in the morning, without hav- ing been conscious of what took place during sleep. These are circumstances which, even if occurring in persons apparently enjoying the most perfect health and unimpaired faculties, should make a medical man suspect the possibility of nocturnal attacks. 748 ON EPILEPSY. I wish now to direct your attention most particularly to other phenomena, which modern authors have allowed to pass unnoticed. If you examine an epileptic carefully after one of his fits, or better still, several hours afterwards-the next day, for example-you will often find on his forehead, his throat, and chest, minute red spots, looking like flea- bites, which do not disappear on pressure, and have all the characters of ecchymoses. This is a sign of very great value, and if modern authors have laid too little stress on it, it had not escaped the notice of the ancients. "Videmus, post validos paroxysmos epilepticos [says Van Swieten] vasa cutanea minora quandocunque rumpi, et puncta ruberrima per totam super- ficiem corporis dispersa manere, quae sensim postea evanescunt; ubi verd rupta vasa, vel dilata eorumdem extrema, sanguinem rubrum eructaverint in tunicam cellulosam, tunc latiores maculae et ecchymoses apparent. Medici in praxi versati frequenter haec symptomata observaverunt." Thus, not only are the small red punctae I mentioned observed, but large ecchymoses also, which are produced in the same way, and apart from all contusion. This sign is, I repeat, of considerable importance, for the ecchymoses are a sure sign of an epileptic fit. Thus, an individual will tell you that on waking in the morning he felt pain and heaviness of the head, and that during the night he passed his urine or his motions involuntarily. His speech will be embarrassed, not because his tongue is paralyzed, but because it is painful and swollen from having been bitten, and sometimes cut in several places; and, lastly, you may notice ecchymoses on his forehead and throat. In such a case you can affirm that the patient has had an epileptic fit during the night. These ecchymoses give us, besides, an explanation of the apoplectiform phenomena which characterize the third stage of the fit. I have told you already that most of the individuals seized with an epi- leptic fit remained for a variable period in a state of coma, and, on recover- ing from it, complained of headache, resembling the heaviness of the head which follows a debauch. In some cases, to which I shall revert by and by, the stupor is followed by nervous symptoms of another kind. They have hallucinations, become wildly delirious and maniacal-sometimes so much so, indeed, that they attempt suicide, or try to murder the persons around them. Some, again, suffer from cerebral disorders for two or three days afterwards, such as complete or partial loss of memory, incoherence of ideas, and perversion of the intellect. Now, looking at these ecchymoses of the subcutaneous cellular tissue, one may well ask whether some similar lesion of the cerebral tissue has not occurred, of the meninges, or of the spinal cord, and whether those lesions could not, in a certain measure, account for the brain symptoms which showed themselves; whether, for instance, they could not explain the paralysis which occurs in some in- stances,'and lasts for four, six, and even ten days after a fit, disappearing then, in general, completely, until reproduced by another fit, but in some cases persisting until death. The existence of these cerebral or spinal lesions has been ascertained in several post-mortem examinations. Calmeil, and other writers on epilepsy, have pointed them out. Not only have there been found on the surface of the brain red punctse, like the subcutaneous ecchymoses, but blood-effusions have also been met with in the meninges, the substance of the brain or spinal cord. Softening, even, of these organs has been noticed, and an instance of this fell under my own observation, in the case of a young girl who died in the St. Bernard Ward, four days after her admission into the Hotel-Dieu. She was sixteen years old, and looked of a feeble consti- tution. She had been for three months subject to epileptic attacks, and a ON EPILEPSY. 749 near relative of hers was affected in the same way. Her fits were exces" sively violent, and recurred four or five times in the twenty-four hours. One of them occurred in my presence, and there could be no hesitation about the diagnosis. The convulsions lasted one minute at the most, were accompanied by contractions of the hands and feet, of the muscles of the neck, and of rigidity of the base of the chest, which rendered respiration anxious and difficult. On the fourth day after her admission she died in a condition of pro- found stupor, after several attacks recurring one upon the other, and leav- ing rigidity of the limbs in the intervals. Dissection disclosed extreme softening of the spina] cord, the substance of which ran out through the incision made into the meninges. The spinal column had been laid open with the greatest care, so as not to injure its contents in any way, and thus avoid all source of error. On slicing the brain, a small clot, the circum- ference of which was beginning to soften, was found about the middle of the left posterior lobe. The brain-tissue was of normal consistency every- where else, and slightly injected. The chief viscera presented no appre- ciable structural change. Lasting apoplectiform symptoms, and paralysis which is more or less per- manent, are in all probability, therefore, due in a certain measure to appreciable material lesions of the nervous centres. I hasten to add, that those lesions, congestion, hemorrhage, or softening, cannot be regarded as causes of the epilepsy itself; nor can the serous effusions which are sometimes met with in the cranial cavity or in the cerebral ventricles of individuals who have died after a fit, be looked upon as causes of the disease. These anatomical lesions are effects of the complaint, and no more, as it has long ago been proved by those who have studied the question. I, of course, allude to epilepsy proper, for we shall see that in cases of so-called symp- tomatic epilepsy the epileptiform phenomena are more or less directly dependent on the existence of brain-lesions, such as bony tumors, cancer of the brain, syphilitic or tubercular deposits, &c., which it is generally pos- sible to diagnose during life, and which are revealed by a post-mortem examination. With regard to idiopathic epilepsy, some authors-among others, Bou- chet and Cazauvielh-have pretended that they have always met with characteristic lesions, such as an induration of the white substance of the brain. But the cases they give by no means prove their assertion, and most, if not all, physicians are now agreed that the most delicate post-mor- tem investigations only give negative results respecting the organic condi- tions under which the disease is developed. I do not deny, however, that the cerebral disorders which constitute epilepsy depend on a material lesion of the nervous centres. When speaking of apoplectiform cerebral conges- tion, I gave you my opinion on that point. I then told you, and I repeat it now, that I do not conceive a functional lesion without an alteration of the organ which discharges the function; but I maintain that we have not yet been able to discover the nature of this alteration, and that the ana- tomical lesions which we find on dissection are the effects, not the causes, of the disease. I shall pass rapidly over the determining causes of epilepsy, for the influ- ence of the greater number of those which have been mentioned as such is far from being proved. It has thus been said that epilepsy sets in more frequently in women at puberty, about the first menstrual period, and that the cessation of menstruation is also another cause of the disease. The part played by menstruation is very doubtful, however. Epilepsy is met with at all ages, although it occurs more commonly during adolescence in both 750 ON EPILEPSY. sexes. If it occurs more frequently than is generally believed in early life, as I shall show presently, it does not spare individuals advanced in years. On May 16th, 1857, Dr. Fantin (de Seineport) brought me an old farmer, seventy-three years old, who, for the last four years only, had suffered from epileptic fits. They first occurred during the night; and on waking in the morning he felt stupid, and complained of soreness of the tongue. Under the influence of belladonna, perseveringly administered for three years, the convulsive fits entirely disappeared, and he only remained subject to fits of absence, recurring every month, and sometimes at shorter intervals, and lasting sometimes from fifteen to twenty minutes. During these seizures he spoke incoherently; and on recovering himself he felt no fatigue, but had no recollection of what had passed since the beginning of the attack. One of the most celebrated military men of our time became epileptic when eighty years old, and died in a fit thirteen years afterwards. Errors in diet, excessive drink and venery, masturbation, prolonged chas- tity, forced intellectual labor, overstraining of the mind, violent moralemo- tions, &c., have often been put down as causes of epilepsy, but their real share in the production of the disease is yet to be proved. Of all these oc- casional causes the influence of fright cannot be denied, and has been noted by every physical!. I have myself ascertained the fact on several occasions, but I am far from believing it to be so frequent as stated by patients and their friends. Very recently I was consulted by a Brazilian, whose first attack seemed to have been manifestly brought on by fright. Whilst on a long journey through his country he had gone to a lonely inn, whete he happened to witness a quarrel between some individuals who were armed, and who, from high words, came to blows. One of the men, mortally wounded by the discharge of a gun, as well as stabbed with a knife, fell down dead in his presence. He was horribly affected -by the scene, and a few days afterwards, whilst dining with a friend, he was seized with epileptic vertigo. Since that time, and for the next five years, he was every day affected in the same way. The attacks were ushered in by a sensation of great heat, beginning at the navel, and rising up the back, which was followed by absolute loss of con- sciousness for the'space of two minutes or so. They sometimes passed away so quickly that they were not noticed by anybody near him. At the end of five years, convulsive seizures supervened, which were at first mistaken for apoplexy, and recurred at intervals of from twenty to thirty days. The vertigo disappeared from that time. He was treated by a physician at Rio Janeiro, and for the space of four years and eleven months he was free from an attack. After this interval the convulsive fits recurred again, as intense and as regular as before, persisting for six years. They then became less violent again, although more frequent, and occasionally attacked him during the night. He stated positively that no member of his family had ever been similarly affected. It is not difficult to collect analogous instances. Thus Leuret (in his "Researches on Epilepsy," Archives Generales de Medecine, 1843) states that of sixty-seven cases of epilepsy observed by himself, the first symptoms of the disease showed themselves after a fright in thirty-five. I do not wish, however, to leave you under the impression of Leuret's too absolute doctrine. Whenever I see a case of epilepsy I carefully in- quire into the cause; and although the patient in most cases imputes his complaint to fright, on closely questioning him I find, however, that in almost every instance the attacks occurred only weeks, months, and even years after the fright. I besides ascertain that this fright was not more severe or more repeated than in the case of a great many children who have ON EPILEPSY. 751 never had fits. The patients only repeat what they heard from their friends, and in most cases when I can question the friends themselves and obtain the truth from them, I find that there have been members of the family affected with insanity, epilepsy, or idiocy, and that the pretended fright only served as a pretext to hide the true cause, namely, an hereditary taint. I do not mean either to deny the influence of emotions felt by a preg- nant woman on the foetus in utero; but I believe that this cause has, like the rest, been extremely exaggerated. Let us now study the different forms of the disease. I have already told you that an epileptic fit lasted rarely more than two or three minutes. I maintain this assertion, and I add further, that an attack lasting from four to six minutes is of such rare occurrence that a medical man may live for years among epileptics without observing a single one. And yet you have heard of cases in which the attacks have lasted two or three days, and have terminated in death. This is the condition which has been termed status epilepticus at Bicetre and the Salpetfiere. The contradiction between these facts and my proposition is merely ap- parent. The status epilepticus is characterized, riot by a single attack, but by a series of attacks, and what then happens is as follows: The epileptic has a convulsive fit, just like a parturient woman is seized with eclampsia. In both cases, the stupor which succeeds the convulsions lasts from ten minutes to three-quarters of an hour at most. But before the stupor has passed away another attack, exactly similar to the first, supervenes, and is confounded with it. Now, as the third stage of an epi- leptic fit is not usually regarded as distinct from the convulsive stage, the patient seems to be still in a fit, although his comatose condition is only an effect of the fit. He has not, therefore, got over the disturbances caused by the first attack before a second occurs, then a third, a fourth, a fifth ; and in proportion to the recurrence of the fits the cerebral congestion increases, the apoplectic coma is prolonged, and extends over a period varying from two to twenty-four hours, and after a time the patient does not recover his senses at all. In some exceedingly rare cases the convulsions last a longer time than I have stated; but such cases are so exceptional that at Bicetre and the Sal petriere, where a considerable number of epileptics are gathered together, and where, consequently, from forty to fifty attacks may be seen in one day, as Dr. Calmeil did, two or three months, and even more, may elapse without a single one of the kind occurring. In the status epilepticus, when the convulsive condition is almost contin- uous. something special takes place which requires an explanation. The patient has a fit of haut-mal, then every two seconds slight convulsive move- ments, transient and scarcely visible, affect his face, his neck, and his limbs, and these recur in the same way for the space of from two to five hours. This is assuredly a continuous convulsive attack; but it should be observed that it is no longer an attack of haut-mal, but quite a different and special form of seizure, dependent on a peculiar irritable condition of the brain and spinal cord. This is what should be meant by a continuous attack; and this form, besides, occurs more frequently in cases of eclampsia than of epilepsy. I have described epilepsy to you in its most familiar form, and it now remains for me to say that the haut-mal varies in intensity, in violence, and in suddenness of seizure. Some individuals are struck down without any premonitory symptom, and without uttering a cry. In others, whilst they are being spoken to, their knees gradually bend, and they fall down sense- less, without the least convulsive movement. Although rare, such cases are yet met with. 752 ON EPILEPSY. Some time ago, a child affected with this singular form of epilepsy was brought to me. His friends were telling me how he was attacked four, five, and even six times in an hour, when he suddenly slipped from the arm- chair in which he was sitting, and fell down on the carpet. I examined him carefully, but detected nothing approaching to convulsion. Another individual, about whom I was also consulted, had similar at- tacks two or three times a week. The seizures at first set in with hallucin- ations which lasted half a minute, during which time he stared vacantly, with his arms hanging down by his side. The symptoms then became modified, and he lost his senses during attacks which lasted about ten minutes. The case being mistaken for one of cerebral congestion, leeches were applied, but after this a second attack came on, which was accompa- nied by convulsions of the face and rolling of the eyeballs. This form of epilepsy consists, then, in mere giddiness, and seems to leave behind it scarcely any consequences, any immediate ones at least. The patient, on getting up, looks a little bewildered, but is soon able to resume the interrupted conversation, as if nothing had occurred. The attack does not proceed beyond the first stage, and although strong enough to prostrate the patient, it does not pass on to convulsions. In other cases, on the contrary, the first stage is absent. The epileptic falls down, his upper limbs, sometimes his eyes alone, are agitated convul- sively, and he then gets up almost immediately, scarcely feeling a little stupid, and somewhat mentally confused for a short time. In other instances, again, the fit occurs as usual, but is extremely slight. There are tetanic convulsions, but only for an inappreciable time; clonic convulsions follow, and after a few seconds the stage of stupor comes on, and is as transient and as slightly marked as the preceding. The patient then gets up, and the attack has scarcely lasted a minute. These are very different forms from those which we were studying just now; and they are, as it were, transitions between attacks of liaut-mal and other manifestations of epilepsy to which I am now about to call your attention more particularly. Keep these facts well in mind. No case of epilepsy is more genuine than that in which the fit occurs quietly, without any extensive movements, and without much noise. If an attack of liaut- mal can be sometimes so well feigned as to deceive those who are not thor- oughly familiar with it, it is quite different with the small seizures, with the fits of vertigo, which I am now proceeding to consider. § 2. Epileptic Vertigo.-Aura Epileptica.-Partial Epilepsy.-Angina Pec- toris.-Painful Spasm of the Face. Vertigo, gentlemen, is a manifestation of epilepsy which is least familiar to medical practitioners, and errors of diagnosis are committed every day, which may be followed by dangerous consequences, through a very grave disease being represented as a trifling ailment. Let me first cite a certain number of instances of vertigo, and thus at- tempt to show you the numerous forms which it may assume. But remem- ber that however various the forms, the disease is always the same, and that these transient strange phenomena which sometimes consist only in giddi- ness, in a sort of astonishment, in ecstasy, or in what has been termed a fit of absence, are identical in their nature with the violent convulsions which characterize an attack of haut-mal. Nay more, vertigo is to a certain ex- tent much more characteristic of epilepsy than convulsions are. The latter, indeed, may be a symptom of other diseases which, however much they ON EPILEPSY. 753 differ from epilepsy, are frequently confounded with it. Thus, in females, hysterical fits resemble epilepsy so closely as to be mistaken for it, and those who have had occasion to observe a good many cases of hysteria, as at the Salpetriere, know how difficult it is in some cases to distinguish between the two affections. Epileptic vertigo, on the contrary, as well as the vertigo of eclampsia, has a special physiognomy, which, when once studied and looked out for, cannot be confounded with anything else. Inquire carefully into the case of an individual suffering from this form of epilepsy, and especially if the patient be a youth or a child, you will recognize a more or less distinct manifestation of the disease by the symp- toms he will describe to you. I have already pointed out the transformation of the symptoms into one another. In general, vertigo precedes the convulsive form, but the reverse sometimes obtains. The haut-mal, which had been the first manifestation of the disease, becomes modified; the attacks diminish in violence, and the individual becomes subject to petit-mal only (another name given to epilep- tic vertigo). An instance of this, as you know, occurred in the case of a young man lying in bed No. 18, St. Agnes Ward. Nor is it uncommon to see convulsive attacks and vertigo develop themselves simultaneously, or the latter appear at least in the intervals between the former, or even usher them in. A gentleman came one day, from Berry, to consult me. During the short time he remained in my consulting-room, he was seized with vertigo, characterized by jerking bursts of laughter. The fit lasted a few seconds only, and he immediately recovered himself; but he seemed very much sur- prised when I asked him why he had laughed: he was not conscious of what he had just been doing. The convulsive attacks to which he was subject were almost always ushered in by these vertiginous seizures. The concomitant existence, or alternating production, of these various morbid phenomena, clearly point out their connection and their identical nature. Let us now rapidly review some of the forms assumed by epileptic ver- tigo, keeping in mind that these forms vary indefinitely, and that it would be vain to try and describe them all. You remember a young girl, aged 16, who, for a long time, was in St. Bernard Ward, and to whose case I have already alluded in a former lec- ture. You remember the seizures to which she was several times subject in the course of the twenty-four hours, and which I witnessed on several occa- sions with you, when going round the wards. She suddenly lost all con- sciousness of her acts, and dropped, or more frequently threw away at a distance, anything she might be holding. Sometimes she would then jump about, turning round her bed as if she were looking for something; at other times, she would fall down, whilst her face grew pale for a moment, and her eyes rolled convulsively upwards under the upper eyelid, and looked strangely fixed; on other occasions, again, she would keep clapping her hands rapidly. If she happened to be seized in bed, she sat up, and took hold of the bedclothes, as if she wanted to cover herself up. The attack scarcely lasted half a minute, and as it passed off, she called out, " It is over." Very slight and very transient stupor then followed. But a very remarkable circumstance in this case was that if an attempt were made to take from her an object which she might be holding at the time of her seizure, she rushed on in a kind of rage, in order to gain possession of it, and struggled until the fit was over. She stated that her illness dated from the previous year only, and had set in with vertigo, or what she termed " fits of surprise." She had as vol. i.-48 754 ON EPILEPSY. many as a hundred attacks in one day, and occasionally had convulsive fits. She had no warning whatever. Her father and mother had never suffered from any analogous complaint, but a sister, now dead, had been epileptic. Thus, in the majority of instances, suddenly, and without any premoni- tory symptom, as in an attack of haut-mal, the individual subject to epi- leptic vertigo feels a kind of astonishment, becomes absent, as it were. If he is engaged in conversation at the time, he suddenly stops in the middle of a phrase, and with eyes fixed, looking bewildered, he neither sees, hears, nor feels anything. He is in a kind of ecstasy, and yet he does not fall down. If he has an object in his hands, he drops, or convulsively throws it away from him. The whole lasts from two to four seconds, and some- times more; the attack is then over, the patient recovers himself com- pletely, resumes his occupation or the conversation in which he was en- gaged, and has no suspicion of what has occurred. Dr. Taupin once asked me to meet him in consultation about a little girl, six years old, who had been ill for five weeks, and whom I had al- ready seen. He told me that he had himself witnessed two attacks which had occurred at dinner-time, and the girl's mother also gave an excellent account of what happened. The child, whilst at play or at dinner, stopped suddenly, and turned her head slowly to the right, with her eyes open and fixed. There were no appreciable convulsions, and no distortion of the face. Sensation was so completely abolished that her skin could be pinched or pricked with a needle without her seeming to feel pain. She remained in that condition for the space of four or five seconds, and then recovering herself looked somewhat bewildered and cross. Generally also she then expressed a wish to move about, requesting her mother to take her into the next room. But in a few seconds she was perfectly herself again; and, after drawing a deep sigh, she returned to her play, or went on eating, as the case might be. The attack of vertigo may last a longer time, however, and may consist in, or be accompanied by, more or less marked delirium, manifesting itself by words and acts. On another occasion, I was consulted about a little girl, aged four, who, for the preceding fortnight, had presented symptoms like the above on every other day. She was otherwise in excellent health, had a precocious intelligence, and related very well what she felt. She experienced some- thing like a general shock, according to her own account, and then became unconscious. Her mother, however, told me that her face then assumed a singular expression of cheerfulness and vivacity in some cases, whilst in others the child looked stupid. After scarcely a minute had elapsed, she exclaimed that she was frightened, acted in a strange and disorderly man- ner, and spoke incoherently. These hallucinations were sometimes pro- longed for seven, eight, and ten hours. Within two days the attacks had recurred twice in the twenty-four hours. The mother added that she thought her child's intelligence was getting impaired. A medical man, practicing at Versailles, sent a young girl to consult me, in December, 1860, whose mother and grandmother were healthy, but whose aunt and great-aunt, on her mother's side, were subject to epilepsy. She herself suffered from attacks of vertigo, which were so frequent that I saw four or five of them whilst she was in my consulting-room. She uttered a plaintive cry, and suddenly placing her hand on the pit of her stomach, she slowly turned her head over to one side. Her eyes were at the same time fixed, her face was slightly distorted. Before a minute had elapsed all seemed to be over, and she then got up, looking bewildered, staggered, and sometimes fell down. If anyone came near her, she seemed to feel a sort of terror. I questioned her quickly; but she opened her ON EPILEPSY. 755 mouth and made signs that she could not speak; I asked her to put her tongue out, and to move it about, but she was unable to do so. A few moments afterwards she uttered a few inarticulate words, and on my insist- ing to make her speak, her speech became gradually less embarrassed, and then perfectly natural. The attack lasted four or five minutes altogether. She was very intelligent, and described her sensations very well. She stated that on the accession of the fit she felt acute pain in the epigastrium, which almost instantly extended to the tongue, when it became very in- tense. She then lost her senses for one or two minutes, and, on beginning to come round, she was prevented from speaking by a kind of painful paralysis of the tongue, which gradually passed off. Again, an individual who is subject to epileptic vertigo may, whilst play- ing at cards, and holding in his hand a card which he is going to throw down, suddenly become motionless, shut his eyes or stare before him, and then, after drawing a deep sigh, he may continue to play. These, gentle- men, are types of epileptic vertigo, and I might multiply instances of the same kind. But there are other and different forms, which I will now point out to you. In the above cases, the patient is isolated from the external world; he sees, hears, and feels nothing, and remains perfectly motionless, in a kind of ecstasy. In some instances movements resembling those of 'mastication are performed, followed by the same guttural sound as when saliva alone is swallowed. In other instances, there is some mental confusion or dis- order which lasts a few seconds, a few minutes even, but which escapes the notice of bystanders. Lastly, there are cases in which the epileptic may complete the movements he has begun, and even perform new ones with a certain degree of regularity, although he is perfectly unconscious of his acts. I have on several occasions cited the case of a priest who, whilst officiating as deacon, and incensing the bishop from the thurible, was seized with epilepsy, and still continued swinging the censer, although his head was so strangely twisted round, and his face so contorted, that the fit attracted everybody's attention. He was subject to vertigo, and had been often attacked in the pulpit, or at the altar, whilst offi- ciating. The attacks, however, were so transient, that he had never been obliged to interrupt his sermon or go away from the altar. But as during the fit he sang in a strange manner, and had on some occasions uttered incoherent words, these acts being considered undignified in a priest, he was of necessity suspended. He came to consult me, and told me him- self the above details. I have already mentioned to you, in a preceding lecture, the case of a young amateur musician subject to epileptic vertigo, and who has some- times a fit whilst playing the violin. Strange to say, he goes on playing during the attack, and although he is perfectly unconscious of everything around him, and neither hears nor sees those he is accompanying, he still plays in time. It would seem as if his will were powerful enough to direct the movements of his.hands for a given, though very short time, and as if those movements were guided by memory, the patient performing without a fault the musical phrase which he had read just as his mind became affected. Many of you may recollect having heard me relate the following case: An architect who resides in Paris and has long been subject to epilepsy, does not fear to go up the highest scaffoldings, and yet he is perfectly aware that he has often had fits whilst walking across narrow planks, at a pretty considerable height. He has never met with an accident, although when in a fit he runs rapidly over the scaffoldings, uttering, or rather shrieking 756 ON EPILEPSY. out his own name in a loud, abrupt voice. A quarter of a minute after- wards he resumes his occupation, and gives his orders to the workmen; but unless he be told of it, he has no idea of the singular act which he has been committing. I once knew a gentleman of superior intelligence, the president of a pro- vincial tribunal, who was subject to epileptiform symptoms, but had never had an attack of haut-mal. Some of his relations were of unsound mind, his sister among others. One day, whilst the court was still sitting, he got up, muttering a few unintelligible words, went to the council-room, and returned a few seconds afterwards, unconscious of what he had done. When his colleagues asked him where he had been to, he did not recollect having moved from his place. Shortly afterwards, as he was getting up in the same manner, the usher was told to follow him. He was then seen,to enter the council-room, and make water in a corner, after which he returned to the court, perfectly ignorant of his incongruous act. He noticed him- self, however, that for a few minutes after these attacks his mental faculties were somewhat impaired. I heard of these facts from himself and from his father-in-law. I did not conceal from the latter of what grave import they were, and I recommended that the patient should resign his post. He had some difficulty in deciding upon this step, but one day whilst in court he got up, walked about, and spoke incoherently to the people around. Almost immediately afterwards he resumed his seat, and without any appreciable mental disturbance, continued to lead the debates. His con- duct, however, had caused such surprise that his colleagues told him of it, and fearing lest his fits of absence should be used as reasons for quashing his judgments, he sent in his resignation. It is this same gentleman who, as I told you in a former lecture, suddenly left a meeting at which he was discussing some historical ques- tions, at the Hotel de Ville, ran out into the open square outside, without his coat and hat, avoiding carriages and the passersby, and on recovering himself returned to the meeting. In a certain measure, his condition was somewhat analogous to somnambulism. Sometimes, when engaged in reading, he would suddenly cease, and would repeat with volubility the last verse or the last portion of the phrase at which he had stopped. His physiognomy wore an unusual expression at such times, but he almost immediately took up his book again and resumed his reading. You will not only meet with persons who are able to perform certain acts during the attacks of epileptic vertigo, but also with some who can answer when spoken to, although they are not conscious of their answers. Their condition may be compared to somnambulism, or, better still, to what happens in the case of certain individuals who answer questions during sleep, but do not recollect anything when they wake up. I attended some time ago a young lady suffering from this vertiginous form of epilepsy. During the attacks, her face sometimes wore an expres- sion of terror, sometimes of anger. She made no answer when spoken to quietly, but if addressed abruptly and in a commanding tone, she answered curtly and in a loud voice. She then suddenly paused, and, if addressed in the same way again, she looked bewildered for awhile. Each attack lasted from fifteen to thirty seconds, and when it was over she had no recol- lection whatever either of what she had been asked, or of the answers she had made. I knew a child who used to exclaim, " Go away, go away," whenever it was attempted to make him, during a fit, inhale some ether or ammonia, the smell of which he disliked. I shall next draw your attention to other disorders of innervation belong- ON EPILEPSY. 757 ing to the same group as those we have just studied-I mean what has been termed aura epileptica. These singular disturbances of the nervous system, which sometimes usher in epileptic seizures, are perhaps more frequent in cases of grand-mal than of petit-mal. In some instances, however, which belong, therefore, to the vertiginous and not to the convulsive form, they alone constitute the attack. A peculiar sensation-which the individual compares to a kind of wind or of vapor, or to tingling-starts from some portion of his body, spreads up- wards, and, on it reaching his head, he suddenly falls down in a fit. When the aura begins in the hand or in the arm, the patient feels the strange sensation running along the length of the limb, which is sometimes convulsively agitated to a scarcely appreciable degree. It rapidly spreads higher up, affects the head, and the fit then begins. You will observe this phenomenon in a large number of cases. More or less transient in character, it lasts from one second only to a minute sometimes. In some cases, it does not merely consist in a strange sensation, but in an acute pain, affecting the hand or the foot, running the same course upwards in both cases, and fol- lowed by the fit when the head is reached. In other instances the aura is attended with appreciable material changes in the part from which it first started. A local determination of blood may occur in the finger, for instance, causing it to swell, reddening the skin, and rendering it successively, within a very short time, red, and of a more or less deep violet color; or again, the skin may become excessively pale after having been injected for some time. The swelling is real, not apparent; for rings, previously easy, suddenly become too tight for the fingers. The aura epileptica may be again characterized by sudden convulsive phenomena, as in the case of a little boy, who was in my ward at the Chil- dren's Hospital, in 1848. On several occasions he was seized whilst I was going round the ward, and I heard him call out, " I am taken with it." His hands were first moved involuntarily, the muscles of his face were next affected, and convulsions followed. The case terminated fatally, and, on making a post-mortem examination, I found tubercles in the brain, which were the cause of the epileptiform seizures I had observed during life. A year ago you had occasion to see a similar case-that of a young man lying in bed No. 9, St. Agnes Ward, whose epileptiform attacks were doubt- less owing to a cerebral tumor. He remained in my ward for a month, and during that period I saw him in eight or ten fits. They were ushered in by pain suddenly attacking the foot, which, on being exposed, was seen to be arched and agitated convulsively. The convulsions then extended to the leg; and on his calling out next, " My arm is affected," I could see the arm jerked spasmodically. The convulsions lasted from fifteen to twenty seconds, during which his intellect was perfectly clear, and he continued to talk quite rationally. The aura gradually, but very quickly, extended to the head, and the poor fellow then became unconscious. In both these cases the epilepsy was symptomatic; but, as I shall show you hereafter, genuine and symptomatic epilepsy bear the greatest resemblance to each other-I may even say a complete resemblance with regard to the manifestations which constitute the seizures. The aura may be visceral-that is to say, it may start from some internal organ. It is often misunderstood in such cases, and gives rise to errors of diagnosis, of which you should be told, in order to avoid them. A young person, at the onset of a fit of haut-mal, used to feel an acute pain in the heart, soon followed by violent palpitations, then by giddiness, and by a tendency to syncope. Seven or eight years ago, I was consulted for a child about ten years old, 758 ON EPILEPSY. who, four or five times a day, before as well as after a meal, always with- out any appreciable cause, complained suddenly of a sensation of pressure in the pit of the stomach, soon followed by vomiting. Immediately upon this he felt violently giddy, and turned deadly pale. These phenomena lasted altogether for about a minute. The medical man who had sent the patient to me, believing him to be suffering from dyspepsia, had vainly tried every means for combating it. The suddenness of the attack, the violence of the pain, which the child described perfectly, the accompanying sense of suffocation, the momentary impairment of the intellect, the pallor of the integuments, and, lastly, the rapidity with which these phenomena disappeared, made me write to the usual medical attendant that the case was certainly one of epilepsy. I therefore advised him to keep strict watch over the boy, adding that I was convinced that sooner or later this neurosis would assume more distinct characters, which would clearly point to its real nature. The boy's father refused to believe in my diagnosis, and his medical man concurred with him. The following year, however, I was again consulted; but this time my fears had been realized, and my diag- nosis confirmed, by repeated attacks of epilepsy, from which the boy had suffered. This visceral aura escapes the observation of the physician all the more easily from its simulating other affections in a numerous class of cases. If it begin in the stomach or the uterus, or if it be accompanied by that sense of constriction in the throat which is assigned as one of the characteristic symptoms of hysteria, especially if occurring in a young female, it may be confounded with the aura hysterica. Careful observation, however, and a rigorous analysis of the symptoms, will enable the physician to distinguish the one affection from the other. Although the aura hysterica seems to start from the same point, from the same organ, as the aura epileptica, it does not spread with the same rapidity, nor does it set in with the same sudden- ness. Hysterical spasms, for instance, persist a longer time than the epilep- tic sensations. These latter, whether consisting in giddiness or convulsions, scarcely last a few seconds-one or two minutes at the most-although they leave behind them the apoplectic stupor I have already mentioned. In hysteria the duration of the symptoms is entirely different, aud when they have passed off the patient feels nothing which can be compared with the bewilderment of an epileptic. In general, the sensations which constitute the aura epileptica spread from below upwards; that is to say, they begin either at the extremity of a limb, or in some point of the trunk, and go up to the head. In some cases, however, the aura runs a different course, from above downwards. It begins in the head, in the shape of giddiness or of pain, and, descending with rapidity, spreads to the limbs. In some rare instances, the aura may be both ascending and descending at the same time. Ch. Bonet (Sepulcretum Anatom, lib. i, sect, xii, p. 291) mentions the case of a man, aged 50, whose left inguinal region first swelled, and who next felt a sort of creeping sensation descending gradually along the thigh and affecting the foot; once there it ascended with extreme rapidity to the head. These singular phenomena have been long ago pointed out by ob- servers. Morgagni, in the third letter of his work, De Sedibus et Causis Morborum, cites several cases observed by himself, or reported by con- temporary or former authors, and has a long dissertation on the subject. He quotes, among others, a case of Tulpius, in which a fit was brought on by pressing with one finger the region of the spleen. I have told you that the aura epileptica is sometimes the only manifesta- ON EPILEPSY. 759 tion of epilepsy. Indeed, it sometimes happens that it is entirely limited to the point where it first shows itself, or at least does not spread far. It does not spread to the brain, and causes none of the phenomena which more essen- tially characterize the disease. Those are cases of what might be termed partial epilepsy. When I was physician to the Necker Hospital, I had under my care a woman, who suffered from these attacks of convulsive aura, four, five, and even seven times in an hour. The aura began in her leg, and was limited to one-half of the body; the convulsions were violent, painful, and affected the trunk, the arm, and the face. Whilst they lasted, she cried out with the awful pain she felt. Her mind remained perfectly clear, although her speech was somewhat embarrassed, owing to the convulsion of the muscles of her face, and, probably, also those of the tongue. The at- tack lasted from a minute to a minute and a half; after which time she re- covered completely. She was rapidly cured by belladonna. A good many cases of angina pectoris are certainly a form only of par- tial epilepsy, as I shall prove to you hereafter, when treating of that dis- ease. I shall show you, that if the awful pain which characterizes this affection generally starts from the precordial region, and from there shoots through the chest to the throat and to both arms, mostly the left arm, causing numbness of the limb in which it has been most intense, and at- tended with a feeling of anxiety and undescribable terror, the pain may, in certain instances, follow7 a contrary course-may, for instance, begin in the arm, and subsequently radiate to the throat, attack the precordial region, and bring on the sense of anxiety. The young man, lying in bed 18, St. Agnes Ward, presents us with another instance of partial epilepsy; and in his case, the order in which the phenomena occur can escape nobody. His complaint, as you remember, set in at first with convulsive attacks, which gradually became less and less violent, and at present they consist in convulsions of the face, exclu- sively confined to the left side, and unattended with loss of consciousness. He feels at the top of the chest a painful sensation, which suddenly extends from the trunk to the face, producing a quivering of the latter. In this case there is also embarrassment of speech, due to the involuntary contrac- tion of the muscles of the tongue and cheeks. Perhaps we ought to place by the side of these partial epilepsies an affec- tion the study of which is highly interesting, and which I mean to bring before you at a future period. It is that affection which I have named epileptiform neuralgia, between which and the different forms of aura, and, consequently, the other forms of epilepsy which I have pointed out to you, a connection may in some measure be traced. I have thus spoken at great length, gentlemen, of epileptic vertigo, of the various kinds of aura, and of partial epilepsy, because it seemed to me of the highest importance that your attention should be drawn to them ; more particularly as, generally speaking, the vertiginous form of epilepsy is the one more frequently observed. Another characteristic of this form of the disease is the great frequency of the fits. The patient may have as many as fifty and one hundred attacks in the course of the twenty-four hours, whilst this is never the case with the convulsive form. Besides, epilepsy presents the greatest irregu- larity in its course and its progress, in the frequency of the seizures, not only in different individuals, but also in the same person. I shall not revert to what I have already told you concerning the exclu- sive preponderance of the convulsive attacks in some individuals, and of vertigo in others, or of their respective transformation, or again, their simultaneous existence. You recollect my telling you also of patients 760 ON EPILEPSY. being attacked in the daytime only, or alternately at night and in the day- time ; whilst others, in much more numerous instances than is generally believed, are only seized at night. With regard to the frequency of seizure: some persons may, in the whole course of their lives, have very few attacks, these attacks recurring at variable intervals ; or they may have a single attack only. Sometimes the fits come on periodically, at nearly equidistant intervals, or they follow one another in rapid succession, as in a series, and then cease for a pretty long time. In other instances, they recur every two months, every month, every fortnight, every week, and even every day. They may again be so frequent, as in the condition termed status epilepticus, that they run into one another as it were, and simulate a continued attack which lasts over two or three days. The fits of petit-mal being so considerably more frequent than those of grand-mal, it is perfectly conceivable then, that dementia should be more rapidly brought on in such cases, since the central disorders which precede, follow or accompany the epileptic seizures, being repeated at shorter inter- vals, more quickly produce impairment of the intellectual faculties, as an almost fatal consequence. § 3. On the Relations of Epilepsy to Insanity. " Epilepsy," says Esquirol, " is a dreadful complaint, not only on ac- count of the violence of its symptoms (in the convulsive form), and not only driving one to despair on account of its incurability, but also because of its fatal influence on the physical and moral condition of its victims. The functions of organic life are impaired and become languishing. Epi- leptics are subject to cardialgia, flatulence, spontaneous lassitude, and trembling ; they take little exercise, and become either obese or emaciated ; they have a tendency to venery and onanism. Perhaps the excesses they commit are the cause of the organic lesions and of the disorders which manifest themselves when epilepsy has lasted a long time. They do not, as a rule, live to an advanced age. The cerebral functions, the intellectual faculties become more and more degraded."* You are well aware that this fatal influence of epilepsy on the intellec- tual faculties, of which dementia, idiocy, and general paralysis are the ultimate expression, is a well-known fact, which has been long ago pointed out by observers. If there have been epileptics, who, in spite of more or less frequent attacks, have retained, to the end of even a pretty long career, not only the fulness of their reason, but also the full force of their intellect, and like those men of genius, whose names history has handed down to us, have preserved that superior intelligence which enabled them to rise above the ordinary level of their fellow-men, instances of this kind are too exceptional to invalidate in the least the general law. In the great majority of cases, although at the beginning, and when the attacks are infrequent, the patients are in full possession of all their faculties, although "a marvel- lous aptitude for conceiving things quickly, or viewing them under their most brilliant and poetical aspects, may distinguish some of them," as Dr. Morel has remarked, yet in proportion as the fits recur and increase in fre- quency, in proportion as the disease progresses, the faculties fail, are im- paired, become gradually extinct, and insanity follows. * Esquirol : "On Mental Diseases,'' vol. i, art. Epilepsy, pp. 282, 283. ON EPILEPSY. 761 Often, also, in individuals whose intellectual activity is perfect, a singu- lar changeableness of feeling, of temper, and of character, violent fits of passion which they cannot master, point to a particular mental condition, which, in the greater number of cases, will be followed by physical phe- nomena of a more distinct character, but always of the same order, as well as by more serious cerebral disorders, such as attacks of delirium, some- times transient, sometimes prolonged, and then specially deserving the name of epileptic insanity. In general the cerebral disturbance is connected with the so-called phys- ical symptoms of the disease, namely, the attacks of convulsions or vertigo, and manifests itself in the interval between the seizures, at their onset, or, more commonly, more or less immediately after them. In some cases, however, these psychical phenomena seem to be the only manifestations of epilepsy. On the whole, the course which they run is very characteristic, and possesses considerable medico-legal importance. This point in the history of epilepsy has, within the last few years, been the subject of special study, and has given rise to numerous memoirs, among which I shall mention that of Dr. Jules Falret.* " The intellectual disorders observed in epileptics," says the author (from whom I borrow the greater part of what I am now going to tell you), " may be divided into three principal categories: 1st, those which, mani- festing themselves in the intervals between the attacks, are independent of these, and constitute the habitual mental state of epileptics : 2d, those which occur temporarily before, during, or after the attack, and may be considered as epiphenomena of the attack itself; 3d and last, intellectual disorders, more or less prolonged, which coming on in paroxysms, either directly connected with the convulsive or vertiginous phenomena, or occur- ring independently of these, specially deserve the name of epileptic insanity." Although some epileptics may, through life, be in full possession of all their faculties, and may manifest in their conduct no sensible change, at least in the beginning, or when they are subject to infrequent attacks only ; in the vast majority of instances, however, those, particularly, who are subject to more or less repeated attacks, present in the interval between the seizures, certain phenomena manifestly dependent on a particular mental condition, which cannot yet be termed insanity. The predominating element in these phenomena is an extreme change- ableness of temper and of mental dispositions ; a true intermittence of the psychical phenomena referable to the affections and the temper, or belong- ing to the intellectual faculties. Thus they sometimes look sad, peevish, desponding, as if under the influ- ence of grief or of shame, arising from their awful complaint; at other times, on the contrary, they have inward sensations of ease and satisfaction which prompt them to harbor thoughts of rash undertakings, or to conceive pro- jects which they can least realize in their sad condition. Sometimes they are querulous, inclined to controversies, to discussions, to quarrels, and even to acts of violence ; at other times, on the contrary, they evince a gentle, benevolent, and affectionate disposition, and religious sentiments of sub- mission and humility as exaggerated as their previous behavior had been. " The same contrasts which are observed in their feelings, are also noticed in the degree of their intelligence, and in the nature of the ideas which occupy their minds. Nothing is more mobile than their mental dis- positions and the level of their intelligence: they sometimes suffer from * Jules Falret : " De 1'etat mental des Epileptiques," Archives Generales de Medecine, 1860, Avril et Octobre, 1861. 762 ON EPILEPSY. mental confusion, failure of memory, difficulty of attention and comprehen- sion. They have great difficulty in collecting their thoughts, and are themselves conscious of the obtuseness of their intellect and the confusion of their ideas. At other times, on the contrary, they evince real intellec- tual activity, a rapid circulation of ideas, which corresponds with a certain degree of cerebral excitement. They can, at such times, devote themselves to uninterrupted study, of which they are incapable at other times, and remember certain facts and certain ideas which, on other occasions, they seemed to have completely forgotten. " This irregularity in the state of their feelings and the degree of their intelligence is necessarily reflected in their talk and in their acts. Hence the excessive variability of their behavior towards those about them. For a certain period of their lives they are laborious, punctual, attentive to the duties of their profession, obedient and docile, and those who live with them or who employ them find their intercourse agreeable, or are pleased with their services. But at other times, their conduct becomes suddenly modified, and presents the greatest irregularities. They are then incapable of fulfilling the duties confided to them, become negligent, lazy, and indolent. They forget the most elementary things, waste their time, or wander here and there, without aim or object in view ; and are themselves conscious of the vagueness and confusion of their ideas. The most deplorable tendencies and the worst inclinations develop themselves in them at the same time: they become liars and thieves; they pick up quarrels with those around them, complain of everything and of everybody; are very easily irritated for the slightest cause, and even frequently commit sudden acts of violence, which, in most cases, have not the excuse of provocation on the part of the victims to those acts."* We have seen, gentlemen, that in the vast majority of cases, if not in all, epileptics are completely unconscious during their seizures, and that this loss of consciousness is even one of the characteristics of the malady. We have also seen that in some cases, instances of which I related to you, the patients, although uncognizant of the outer world, utter certain words and perform certain actions as what obtains in natural somnambulism. I will add that, whilst some individuals have no recollection whatever of what has occurred, others remember more or less vaguely the ideas which occupied their mind, and have a confused notion that they were then, as it were, " under the influence of a painful dream, of intense pain, or of deep remorse; or, again, of a sense of some unavoidable misfortune, which they could not account for." These singular intellectual disturbances principally occur in those epileptic attacks which, according to J. Falret, hold a medium place between simple vertigo and convulsive fits, and which are incomplete with respect to the disorders of movement as well as the loss of conscious- ness. But the psychical phenomena which may show themselves before or after the fits are much more interesting to study, and much more important to know. By the side of individuals who are seized suddenly, without any premonitory symptoms, you will observe others in whom appreciable changes of temper foretell, like clouds, forerunners of a storm, that a fit will occur more or less shortly. " Thus, for example, certain epileptics become sad, peevish, quarrelsome, irritable, often for several hours before a fit; others complain of slowness of conception, of failure of memory, of obtuseness of ideas, of a kind of hebetude, or physical, and moral prostration, which to those used to their society or to themselves are sure signs of an approaching fit. Others, on the contrary, are unusually gay, have an exaggerated sense * Jules Falret : loco citato. Dec., 1860, p. 669, et seq. ON EPILEPSY. 763 of physical and moral wellbeing, an excessive confidence in their own strength, and sometimes even get into a state of loquacious restlessness which may be pushed on to maniacal excitement or to violent bursts of passion. " Apart from these premonitory symptoms, which may come on at a vari- able time previous to an epileptic seizure, there are other prodromata of the same order, a sort of intellectual aura which precedes the convulsion by a few minutes only, and constitutes its first symptom in a certain measure." These prodromata consist in hallucinations, illusive sensations, varying indefinitely in different individuals, but recurring in the same person with singular uniformity. Thus, a young person, subject to epilepsy, told me that at the beginning of a fit she heard voices and sounds which were re- markably harmonious and melodious. Other patients declare that they hear sounds of bells, or a voice uttering the same word in a determined tone. Others, again, always smell a par- ticular smell, or see a ghost, flames, fiery circles, frequently red or purple objects, or (as in the case of the Brazilian whose history I related to you) the objects around them look unusually bright and beautiful, and form a magic spectacle. These strange and excessively variable sensations resemble those of individuals under the influence of hashish. Lastly, in other cases, the intellectual aura consists in the recollection of a fact, or the re- production of an idea, which on a former occasion either caused, or at least accompanied the fit. "Many persons," says Dr. J. Falret, "who have become epileptics after strong moral emotions or intense terror, see again in spirit, or before their eyes, on each succeeding seizure, the painful cir- cumstances or the dreadful scene which first produced their complaint." A young man, aged seventeen, who was in the wards of my esteemed colleague, Dr. Carl Potain, presented us with an example of these singular phenomena. His father had on several occasions manifested suicidal ten- dencies; his mother was said to have been subject to convulsive attacks, perhaps of epilepsy, but at the very least of hysteria; and his first fit, which had occurred when he was eleven years old, had been caused by the deep impression made on him by his mother's decease. On the accession of every fit, which now returned frequently, this painful circumstance in- variably recurred to his mind. "Z am seized through my thoughts," he used to say, and he explained to us that his thoughts were always the same, and constantly referring to his loss. Epileptics usually remain after their attacks, for a length of time vary- ing from a few minutes to several hours, in a state of more or less marked torpor or semi-hebetude. They have a difficulty in co-ordinating their ideas, in recognizing the persons or objects around them, and their mental confu- sion, especially the failure of their memory, lasts for one or two days. But if this be the usual state of things, it does not infrequently happen that this perturbation of the intellect, after having expressed itself by stupor and prostration more or less prolonged, suddenly manifests itself by cerebral excitement, by a furious delirium which prompts the unfortunate patient to the commission of acts of the most violent character, so much so, indeed, that no madman, as everybody knows, is more vicious or more dangerous. " No one," says the author of the excellent memoir which I recommend you to read, "no one can form an accurate notion of the sort of rage which suddenly possesses the epileptic, and drives him to strike or to break any- thing which he can lay hold of. During these transient attacks of furor, he is so dangerous to those around him, as well as to himself, that the at- tention of persons in authority and of medical men cannot be too earnestly drawn to these conditions of instinctive and blind violence, which all au- 764 ON EPILEPSY. thors have pointed out as frequent results of epileptic fits. They may lead to the infliction of grave wounds, to the„commission of suicide, of homicide and arson, and yet the individual cannot be held responsible in any degree for the acts of violence perpetrated by him during this perfectly automatic though short-lived delirium.* In a former lecture on apoplectiform cere- bral congestion, I related a few instances of this kind. I need not revert to the subject, but will merely add the following case, which many of you will doubtless remember: At the end of December, 1860, a young woman was admitted under my care into the St. Bernard Ward, in a state of wild delirium, which was said to have commenced a few hours previously. I told you at the time that she was epileptic, and on the next day her husband communicated to me some important facts which entirely confirmed my diagnosis. He told me that his wife had suffered from epilepsy for more than a year, and that on the day preceding her admission into the hospital she had been seized with transient vertigo, followed by wandering for a few minutes. During the night she had a severe epileptic fit, after which the delirium had set in. This attack lasted five or six days. " In some cases the delirium, which may last a few hours only, persists for twelve or fifteen days, although it generally passes off after two or three days. In some individuals the temporary intellectual disorder which suc- ceeds an epileptic fit does not show itself in its usual form of instinctive, blind violence, but assumes the form of more or less marked simple ma- niacal excitement. The patient talks incessantly and incoherently. He moves about restlessly, and executes movements that are more disorderly than violent. He is sometimes under the influence of delirious ideas of an agreeable nature, which rapidly alternate with conceptions of a painful kind, and frightful hallucinations, chiefly of vision. But this temporary maniacal delirium consists in a rapid succession of incoherent thoughts, and in great disorder of actions, rather than in extreme violence, as is on the contrary observed in the class of patients we spoke of before."! I now pass on, gentlemen, to the consideration of the morbid psychical phenomena, which, in the division I borrowed from Dr. Falret, are com- prised in the third category. They are those intellectual disturbances which occur either in direct connection with convulsive and vertiginous symptoms, or independently of them, in the form of more prolonged at- tacks, and deserve more especially the name of epileptic insanity. A detailed description of these phenomena is of such vast importance to the practitioner, that I will quote in full the following extract from Dr. Falret's memoir : " Two forms of well-characterized intellectual disturbance, constituting genuine attacks of insanity, may occur in epileptics at various intervals, and as irregularly as the convulsive seizures themselves. They are some- times directly connected with those seizures; but may at other times be in- dependent of them. They are often confounded together in a common de- scription, but they deserve to be described separately, in spite of the points of resemblance between them. In order clearly to distinguish one form from the other, we shall give them names which will have the peculiar advantage of recalling the striking analogy which exists between them and the two kinds of seizures which authors have pointed out. We shall call one form petit-mal, and the other grand-mal; meaning thereby to indicate the close relationship observed between the physical and the mental mani- festations of epilepsy." * Jules Falret: loco cit., p. 967. f lb., p. 697. ON EPILEPSY. 765 " Petit-Mai.-The patient suffers at intervals from a more marked intel- lectual disturbance, which lies midway between the slight degree of impair- ment characteristic of his habitual state, and the attacks of furious mania of which we shall speak presently. This intellectual disturbance, the dura- tion of which varies from a few hours to several days, recurs in paroxysms. It consists principally in a great confusion of ideas, accompanied in most cases by sudden instinctive impulses and by acts of violence, phenomena entirely special to epileptics, and intermediate between the mental lucidity of partial delirium and the complete disturbance of general delirium. u Epileptics subject to this particular form of delirium generally become at first sad and morose without cause; then suddenly get into a state of great despondency, attended with obtusion of ideas and feelings of irritation against everything around them. They feel somewhat giddy, they say; they are partly conscious of the vagueness of their ideas, of the failure of their memory, of the difficulty they have in collecting their thoughts and in fixing their attention, as well as of their involuntary violent impulses. The majority of them have in addition, from the beginning of the attack, a deep feeling of their inability to resist a superior force which holds their will in subjection, and drives them, in spite of themselves, to acts of violence. They express this feeling differently according to their education and social position ; but in nearly every case analogous expressions are used to describe the same inward feeling. They say, for instance, that they are no longer themselves; that the disease drives them on ; that they have within them an evil spirit which commands them, &c. They all, in one form or another, speak of their will being driven on, a circumstance which seems to be a characteristic feature of this form of delirium, and which persists, to a vari- able degree, during its entire duration. " Under the influence of this mental condition, such patients suddenly cease their occupations, or leave their homes and wander here and there in the streets or in the fields. This impulsive want to wander about is nearly constant in this mental state, and deserves to be particularly pointed out. The victims of a vague sense of anxiety, of an instinctive and groundless terror, of a want of automatic and undetermined motion, these unfortunates feel sick of life, and wander about without any aim or object in view. In their mental confusion they recall to memory all the painful thoughts which they have had at various periods of their lives, and which spontaneously recur to them unchanged whenever they are attacked. They feel intensely miserable. They believe themselves to be victimized and persecuted by their relatives or their friends. They accuse all those with whom they have been in contact of being the cause of their trouble. If they have previously harbored any feelings of hatred or thoughts of revenge against any one, these feelings are quickened by their complaint, and suddenly roused to a pitch of intensity which prompts them to immediate action. The essentially impulsive and spontaneous character of the epileptic delirium is really very remarkable. In this state of extreme mental disturbance, of general anxiety and instinctive impulses, the patients are apt, in a most sudden and unex- pected manner, to commit all kinds of violence-suicide, theft, arson, and homicide. Some, in order to escape their inward anxiety, attempt to com- mit suicide ; others, under the influence of a similar despair, and of a similar desire to escape their intolerable inward sensations, knock their heads against walls; or, seizing hold of the first instrument they can, strike, or break everything around them, and thus exhaust their rage on inanimate objects. Others, again, rush with fury on the first individual they meet, strike him repeatedly, and, if others come to his help, strike them also. This circum- stance, namely, that repeated blows are struck, and several wounds inflicted, ON EPILEPSY. 766 or several persons injured, deserves to be especially noticed, in our opinion, and seems to us to characterize the condition of furor epilepticus; hence it may be of considerable importance in a medico-legal point of view. " Immediately after the commission of an act of violence, epileptics sub- ject to this form of delirium may get into one of two moral conditions widely differing from one another. In some cases, what they have done eases them as it were, and at once puts an end to their undefined anxiety and their mental confusion. They are like drunken individuals who suddenly become sober again ; they partially recover their consciousness, and begin to under- stand, although very imperfectly, the gravity of their act. In other cases, they continue to run forwards in a state of great excitement and general disturbance-a state in which they are only very imperfectly conscious of the act which they have just committed, or even retain no recollection of it. The very great confusion of the memory, amounting almost to complete forget- fulness of a great number of facts, is therefore, in both cases, an almost con- stant symptom of this kind of delirium. "When the patients recover themselves, either immediately after the act of violence which forms the crisis of their attack, or after a certain length of time, they sometimes succeed, by dint of exertion, in recalling to mind many details of the facts which occurred during their seizures, especially those which happened towards the close ; but their recollections are always very indistinct. This indistinctness has been erroneously re- garded as simulated ; but it is perfectly real and characteristic of this mental condition. The epileptics are then in a state comparable to that which succeeds a painful dream. The principal circumstances of the attack have at first escaped them. They begin by denying the facts im- puted to them ; but by degrees they remember certain details which they at first seemed to have forgotten. On the whole, however, they recollect the facts very incompletely. " Grand-Mai.-In all asylums there are found epileptics subject to this form of delirium, which we shall call the intellectual grand-mal, and which is generally known under the name of furious mania. All authors have noted the extreme violence of individuals suffering from this particular form of mental disease. Several of them have even pointed out some of the characters which allow of a distinction being made between this and other analogous maniacal conditions. We have no intention of describing it here in detail, but will only indicate its chief distinctive characters. Thus, a character special to epileptic mania is the greater rapidity of its invasion compared with that of other forms of mania. Sometimes, in fact, it is preceded by no premonitory symptom whatever. In other cases there are some physical prodromata-such as cephalalgia, vomiting, injection oi- brilliancy of the eyes, alteration of the voice, slight convulsive movements of the face or limbs; or mental symptoms, consisting in sadness, irritability, or slight excitement. But these prodromata precede at the most for a few hours only the explosion of epileptic mania in its most violent form. Another equally important character of epileptic mania (common, after all, to 'most intermittent kinds of mania) is the absolute resemblance of all the attacks in the same patient; not only on the whole, but even in every detail. When the various phases of a first attack of epileptic mania are carefully observed, one is really struck with the fact that the same patient expresses the same ideas, utters the same words, performs the same acts-in a word, goes through the same physical and moral phenomena, on the occurrence of every fresh seizure. His ideas, his language, and his acts are fated, as it were, and recur with surprising uniformity whenever he is attacked. " During these paroxysms, epileptics manifest most of the psychical ON EPILEPSY. 767 phenomena which characterize the maniacal state in general. Their ideas succeed one another with great rapidity. They talk incessantly. They pass without interruption through the most varied series of ideas, and their acts are as disorderly as their language is incoherent. A peculiar feature of their agitation, noted by all authors, consists in the excessive violence of their acts, which violence prompts them to strike and break with a kind of rage all surrounding objects-to bite, tear, and cry without ceasing- and to knock their own heads with violence against the wall. This state of agitation, which passes on to furious excitement, is sometimes carried so far that such patients constitute the most dangerous class of madmen, are universally dreaded in asylums, and can be restrained and protected only by the most coercive measures-such as the strait-waistcoat, or lengthened confinement in a cell. " But extreme violence is not the sole characteristic which distinguishes epileptic mania from other maniacal conditions. An equally remarkable fact is the terrifying nature of their predominating ideas, and the frequency of hallucinations of a similar kind to which they are subject-hallucinations of hearing, of smell, and particularly of sight. They have visions almost constantly : they see frightful objects, ghosts, assassins, armed men who rush on them to kill them. They constantly see luminous objects, flames, fiery circles ; and a circumstance worthy of note is that the sight of blood and red colors frequently predominates in their visions. These attacks of mania, again, present another very important peculiarity. In spite of the disorder and violence of their acts, their language is, in general, consider- ably less incoherent than that of many insane individuals. It is surprising how easily, in spite of their state of agitation, one can follow the train of ideas expressed by epileptics. Their delirium is more connected and com- prehensible than is usual in mania. They understand better the questions that are put to them ; they answer them more directly, more exactly ; and notice what goes on around them more frequently than most insane persons suffering from general delirium with excitement. The less marked inco- herence of the delirium, and the greater distinctness of ideas during the attacks, are all the more remarkable that they singularly contrast with the nearly total obliteration of all recollection of the fit after it is over- a defect of memory which is also an almost constant symptom of the attacks of epileptic mania. " Before concluding this rapid enumeration of the principal characters which distinguish epileptic from common mania, let us add that the attack generally lasts a few days only ; and therefore less than in the other forms of mania. Lastly, its termination is in general as sudden as its invasion. In a few hours, sometimes even in less time, these patients return to their normal condition. Scarcely ever do they in some cases remain for a short time in a state of slight stupor, or of physical and moral torpor, before they regain their reason completely. They recover from their attacks like a man who wakes up after a dream or a painful nightmare ; and they have scarcely any recollection of what has occurred during their seizure."* These two forms of epileptic delirium-the intellectualpetit-mal grand- mal-although presenting differential characters, as distinct as those we find in cases of insanity, between partial and general delirium, have also many points of resemblance which denote their common origin. In both the delirium comes on in paroxysms of relatively short duration when com- pared with those which characterize other mental diseases. Its explosion is sudden, its disappearance no less so; and, after it has passed off, the pa- * Jules Falret : loco cit., p. 671, et seq. 768 ON EPILEPSY. tient has totally, or almost totally, lost all recollection of the ideas which have passed through his mind, and of the acts which he has committed- of his painful thoughts, his frightful hallucinations, and his instantaneous acts remarkable for their extreme violence. The identical nature of these two varieties of epileptic insanity is proved, first, by their frequently occurring alternately in the same individual; secondly, by the fact that either in the same or in different individuals, a great many intermediate conditions may be observed, varying from a sim- ple transient cloudiness of the intellect up to the most furious maniacal excitement; and thirdly, by the more or less direct and immediate connec- tion, in the case of petit-mal, with attacks of vertigo, and in that of the intellectual grand-mal with the convulsive form of epilepsy. The intellec- tual impairment increases in proportion to the number of epileptic seizures, the rapidity with which it sets in depending on the frequency of the fits, for the first period of the disease is almost always free from delirium, this happening more frequently during the middle period, that is to say, when for some years already there have been manifestations of epilepsy, at more or less distant intervals. In the last period, when the attacks have recurred frequently and for a long time, the patients fall by degrees into a continu- ous condition of dementia and idiocy, only interrupted from time to time by phases of agitation of short duration. This dependence of intellectual deterioration on the duration of the dis- ease and the frequency of recurrence of the attacks, explains how it hap- pens that all ages are liable to mental failure. I lately saw a remarkable instance of this in a child aged four years and a half. He had been epileptic since the age of 18 months, when he had first presented vertiginous symptoms, consisting in a kind of hebetude, or bewilderment, which suddenly came over him, and lasted a few seconds. In the space of two months he had five or six attacks, and, after passing a year without any, he became subject, when three years old, to convulsive paroxysms, and to attacks of vertigo, recurring at intervals. When I saw him he had, for the previous three weeks, been frequently seized with con- vulsions, and the vertigo was almost constant. In the intervals between the fits his reason was impaired ; he uttered savage cries, spoke incoherently, and he often bit the persons who waited on him, not excepting his mother. In consequence also of this dependence, to which I attach great impor- tance, we can understand why, in cases of epilepsy occurring late in life, insanity may not be brought on by it. Calmeil has recorded, however, the case of a woman, aged 73, who became insane after a first attack of epilepsy. The reason is, gentlemen, that like the physical phenomena of epilepsy, its psychical manifestations present the same diversities in their course, their frequency, and the order of their sequence. Thus, in some cases-but very rarely indeed-the convulsive or the vertiginous attacks are invariably at- tended with delirium ; in others, and this is what more frequently happens, the convulsions or the vertigo are alone present; in a third class of cases, again, paroxysms of mania alone attract attention, whether these occur in theiintervals between the attacks of grand-mal or petit-mal in known epilep- tics, or in individuals whose complaint is unknown, as in cases of noctur- nal epilepsy for instance; or lastly, whether they affect persons who, at the time of observation, have not for a long period been seized with con- vulsions or vertigo, in consequence of a real transformation of the disease. If it may be stated as a general law, that epileptic attacks recurring fre- quently, and over a long period of time, bring on as a consequence an ab- solute impairment of the intellect, the last term of which is dementia and idiocy, you will meet, however, with epileptics who, in spite of the intensity ON EPILEPSY. 769 and frequent recurrence of their attacks, preserve their faculties in all their integrity, and present only slight perturbations of the intelligence and of the temper, which cannot be termed insanity. Then, also by the side of patients whose paroxysms of delirium return at very short intervals, you will see others whose mind is perfectly sound, and is disturbed only by very few attacks, separated by very long intervals, or, perhaps, by a single attack only throughout their whole life. Setting aside exceptional facts, I shall now conclude what I had to say on this important question, with another quotation from Dr. J. Falret's memoir: " The most favorable conditions for the production of delirium are the following: " When the disease has been for a long time suspended, it often bursts out with fresh intensity, both in the convulsive and the delirious form. " When the fits recur at very short intervals, in a series, and as it were one upon the other, delirium frequently sets in, especially when the seizures are imperfect, incomplete, when the disease does not find a vent, according to an expression used by the patients themselves and by their friends. Thus, in our opinion, can we reconcile the two apparently contradictory opinions expressed on this point by several authors who have especially studied this subject. " Delasiauve, for instance, thinks that ' maniacal symptoms are more likely to show themselves, in proportion as the fits recur at shorter inter- vals, more frequently, and with greater intensity, and in proportion to the duration of the disease.' " On the other hand, Morel* says: " I have noticed that epileptic fits are complicated with exaltation, which is more marked in proportion as the attacks are separated by longer intervals, and as the individuals enjoy their reason more completely during those intervals." In the next page, Morel declares that he also adopts Dr. Cavalier's opinion, touching the greater influence of imperfect epileptic attacks on the production of delirium. These opinions, which are apparently contradictory, may, however, we believe, be included in the following proposition: Delirium chiefly occurs as a consequence of epileptic attacks recurring at short intervals, after a prolonged suspension of the disease. § 4. On Hereditary Taint, as a Predisposing Cause of Epilepsy-Influence of Marriages of Consanguinity. In a former lecture, I mentioned some of the reputed exciting causes of Epilepsy. I wish now to draw your attention to its most powerful predis- posing cause. Hereditary taint has certainly a great influence on the production of epilepsy, and I hardly understand how trustworthy authors can have doubted such a fact, which has been accepted by the generality of prac- titioners. They may have been misled by the circumstance that disorders of the nervous system assume the form of epilepsy in some individuals, and in others of phenomena of an apparently different character. This trans- formation of nervous affections into one another is a vast subject, which I cannot consider now; but if'you question your patients scrupulously, if you carefully inquire into their previous history, you will, in many cases, discover, either in their direct or collateral relatives, symptoms analogous to those which they themselves present, or mental alienation in one of its vol. i.-49 * Morel: "Etudes Cliniques," t. 11, p. 819. 770 ON EPILEPSY. various forms, or mere eccentricities of character or of manner, or, again, disturbances of innervation characterized by strange symptoms, by peculiar nervous phenomena, which indicate an unfortunate predisposition trans- mitted from generation to generation. I will give you a few instances in illustration. The first one which I am going to relate struck me particularly, and from special circumstances I was enabled to study it carefully. A gentleman, now 88 years old, was affected, at the age of 64, with melancholia, of which he is at present per- fectly cured. He had three children, two sons and a daughter. The eldest son is of a melancholic temperament, but of perfectly sound mind ; the second was affected with locomotor ataxy, and died mad. A son of the latter, at present 30 years old, is as yet of sound mind, but has a child who is an idiot. The daughter, who is devoid of intelligence, and is, besides, somewhat strange in her ways, has had two sons, the eldest of whom died insane and paralyzed, whilst the younger one is almost idiotic. This gentleman had also a sister who became mad at the age of 30. This lady had a son and a daughter; the first, from infancy, has suffered from night-blindness, and is now afflicted with epilepsy; the second was amaurotic, and died insane, leaving also a son, who has already given proofs of a notable impairment of the intellect. I was once asked to see a child suffering from epileptic vertigo. His father's intelligence was below the common average, manifestly owing to a defective mental organization, and his mother informed me that a brother of his had for two months been troubled with a strange, convulsive cough, somewhat like hooping-cough, but essentially different from it in many respects. This cough, which had worried him, and incessantly prevented him from sleeping, ceased suddenly after the administration of two granules of santonin, which brought away some ascarides lumbricoides. Those nervous symptoms, that convulsive cough, were not in themselves extraordinary. They have been long ago pointed out as belonging to the train of morbid phenomena caused by the presence of worms; and, among other instances, some of you may perhaps know the case related by Dr. Graves in his clinical lectures. A young girl was for several months troubled with a constant cough, accompanied by fever and unpleasant general symptoms. She lost flesh considerably; so much so, indeed, that Dr. Graves and Sir W. Crampton, who saw her in consultation, believed her to be consumptive, although they never could find any sign of phthisis. The cough persisted; hectic fever and the loss of flesh became more marked; but one day, after having for some little time taken oil of turpentine, which an old nurse gave her, she passed a tapeworm, and was at once cured. In the case of the boy to whom I just now alluded, the nervous symp- toms were not therefore extraordinary; but they indicated an hereditary taint which could not be referred to the father's imbecility, and which in the other boy manifested itself by epileptic vertigo. Such examples of predisposition to various nervous disorders, transmitted from parent to offspring, abound in the records of medicine ; and, among those which have fallen under my own observation, I will mention the fol- lowing : A gentlemen, the son of a celebrated painter, and himself an excellent draughtsman, and a pupil of Gros, had to give up painting-or, at least, to confine himself to sepia drawings-in consequence of a peculiar defect of vision, with which he had been afflicted from birth-namely, inability to distinguish red from green. Thus, the red fruits and red flowers in his gar- den looked to him of exactly the same color as the grass on his lawn and ON EPILEPSY. 771 the leaves on his trees. He was incapable also of seeing the difference be- tween the red ribbon of the Legion of Honor which he wore, and the green ribbon of another order. In all other respects his sight was excellent, so that the defect was as strange as inexplicable, and must probably have been due to a defective organization of his nervous system, although he had never suffered from any nervous complaint. This peculiar defect of vision has, by ophthalmologists, been described under the name of Daltonism; and, in his treatise on Diseases of the Eye, Mackenzie has recorded several examples of it. Now, this gentleman was the father of seven children, six of whom had convulsions in infancy, whilst in one of them, whom I attended for a long period, symptoms of eclampsia complicated attacks of acute catarrh, pneu- monia, measles, and scarlatina, from which he suffered at different periods, and showed themselves as well during his rather difficult dentition. A few years afterwards he was seized with well-characterized epilepsy, which car- ried him off at the age of twenty. Not long ago I had under my care, in the St. Bernard Ward, a woman, aged 40, who for the last three years had been subject to epileptic vertigo. Whenever she was seized she ran quickly straight before her, fell down after a few seconds, but was only partially insensible. When she got up she looked stupid, and continued so for several hours. One of her sisters suffers from similar attacks ; and her father had such a violent temper that he attempted to kill her with an axe for some trifling cause only eight days before his death, which was preceded by nervous symptoms. The hereditary predisposition of an epileptic may therefore he traced merely to strange nervous phenomena, perfectly different from epilepsy itself, whilst similar disorders may alone be manifested by his posterity, di- rect or indirect. I wish, gentlemen, to draw your attention particularly to this fact-namely, that the hereditary transmission of epilepsy, and more generally of various nervous affections (in fact, as is the case with all hered- itary diseases), may be direct or indirect. In a great many cases, for in- stance, on inquiring into the family history of an epileptic you will find, on the father's or on the mother's side, sometimes (but very rarely) on both sides, either original traces of epilepsy, in one of its various forms, or one of those affections of which epilepsy may be merely a transformation, and into which it may in its turn be transformed ; or, again, cerebral diseases-such as soften- ing, hemorrhage, &c. In other, and perhaps more common cases, you do not find these primitive traces of epilepsy in the parents themselves, but you have to seek for them in the grandparents, in the direct or distant relatives, in the maternal or paternal uncles, aunts, and cousins. The hereditary trans- mission may have spared a generation, although the disease, at first latent in the parents, may show itself at a later period in them, after the children have been first attacked. Besides, cannot the same thing happen in epilepsy as in other diseases ? Very trustworthy authors state that "individuals, born of a second mar- riage between a perfectly healthy woman and an equally healthy man, have been seized with the same complaint as the children born of a former mar- riage, a complaint to which the woman's first husband was subject." According to Dr. Olgive, quoted by Dr. Boudin, a woman at Aberdeen, had married twice, and had borne children both times. All of them were scrof- ulous, as her first husband had been, although she herself and her second hus- band were perfectly free from all scrofulous taint.* * J. Ch. M. Boudin.: " Dangers des unions consanguines et necessite du croise- ment dans 1'espece humaine et parmi les animaux (Annales d'hygiene publique et de medecine legale." 2e Serie, t. xviii. 1862). 772 ON EPILEPSY. Vidal (de Cassis),* also cited by Boudin, relates that a woman whose first husband had suffered from very obstinate syphilis, gave birth to a child, who died, after presenting the most marked signs of syphilis. After the death of her husband, this woman, who was perfectly healthy, married again. Her second husband was perfectly healthy ; but, although she knew him alone, she gave birth to a syphilitic child, four years after her first marriage. However inconclusive these facts may be when taken singly, and how- ever strange they may appear, they suggest reflections at the very least, because what happens as a biological phenomenon may occur as a patho- logical fact, both in man and the various classes of animals. Now it is well known to zoologists (and the experiment has been often repeated in domestic animals), that females do sometimes give birth to individuals which bear a marked resemblance to the males by which they were fecundated on a former occasion. To give you an ordinary instance of this. Many of you doubtless know that it is not Uncommon to see puppies resembling, in form or color, those of a previous litter, and in nothing looking like their father. As regards the human species, Dr. Nottf gives cases of negro women, who, after having borne children for a white man, continued to have mu- latto children with a negro husband. According to Dr. Simpson, of Edinburgh, a young woman, born of white parents, and who had a mulatto brother born before marriage, had un- doubted traces of black blood. J Dr. Dyce says that he knew a half-caste woman who had fair children with a European; and who, on being married to a mulatto afterwards, gave birth to children resembling her first husband both in face and com- plexion. Whether they be explained by the impression made on the female gen- erative organs when first impregnated, which impression persists even through succeeding impregnations, or whether they be regarded as inexpli- cable, such facts exist nevertheless, and open up a vast field to the etiology of diathetic diseases, and we should take them into account in our present inquiry. With this question of the hereditary transmission of disease is connected another which engages the attention of serious men, and is more than ever now the order of the day. I mean the fatal influence of marriages of con- sanguinity on the propagation of the species. These influences play some part in the history of epilepsy, and it behooves us therefore to say a few words on them. You doubtless know some of the curious and interesting results obtained from statistical researches made in America, Germany, England, and France. From these researches and especially from those which my learned confrere, Dr. Boudin, has recorded in his memoir, it appears that intermarriages may cause either complete sterility, ora greater frequency of miscarriages; or that they may give birth to children who die in infancy in a greater proportion than those born under other circumstances, or who are less apt to resist dis- ease if they live beyond the first period of life, or who are of a lymphatic temperament, with a predisposition to scrofulo-tubercular affections.§ These intermarriages may, again, beget individuals suffering from degenerations, * " Traits des Maladies Veneriennes 2d ed. Paris, 1855, p. 539. f " Types of Mankind ; " 4th ed. p. 806 (cited by Boudin). J " Gazette Medicale de Paris," 16 Avril, 1859; p. 231 (quoted by Boudin). | Rilliet (de Geneve): "Note sur 1'influence de la consanguinity sur les produits du manage " (Journal de Chirnie, Medeeine et Pharmacie, 20 Juin, 1856), quoted by Dr. Boudin, p. 61 ON EPILEPSY. 773 and physical or moral infirmities; from monstrosities-such as polydactylia, spina bifida, talipes, hare-lip, as in the cases reported by Dr. Devay, in his Traite special d'Hygiene des Families, who adds also retarded dentition as another consequence of the same cause. In the lower animals aZftinwn may almost at will be produced by suc- cessive unions between near relatives; and this singular degeneration in man, of which pretty numerous examples are on record, may perhaps have the same origin. Diseases of the organ of vision may be produced ; consist- ing sometimes in strange defects of sight, at other times in total blindness, or in that affection described under the name of pigmentary retinitis, which is characterized during infancy by a failure of the sight in the twilight, and a diminution of the field of vision by a feeble light; later, at about the age of thirty or forty, by the abolition of vision, or at least of the faculty of guiding oneself, although the smallest type may still be distinguished within very narrow limits of the field of vision. The ophthalmoscope detects, in such cases, grave alterations of the choroid and of the optic nerve; the retina is more or less atrophied, and is covered with cells of black pigment, which unite and form a plexus. * In order to prove to you the relation of these morbid conditions to the intermarriages from which spring the unfor- tunate patients, allow me to quote a few figures from Dr. Boudin's memoir. " Among the issue of 27 intermarriages observed in America, Dr. Bemiss (of Louisville) found two children that were blind, and six who were afflicted with various defects of vision. " Dr. Liebreich, of Berlin, thinks that nearly one-half (27 out of 59) of the individuals suffering from pigmentary retinitis are born of intermar- riages." Of these 59 cases, retinitis coincided with deaf-mutism in 18, and in 2 with idiocy. This coincidence is all the more striking that pigmentary retinitis is very rare; and, as Liebreich remarks, that both diseases simul- taneously attack children belonging to families in which they show them- selves together, but never separately, f Of all the fatal consequences of intermarriages, the most frequent is, without doubt, deaf-mutism. " The proportion of individuals who are deaf and dumb from birth," says Dr. Boudin, " increases with the degree of rela- tionship between the parents. If we assume the risk of giving birth to a deaf and dumb child in an ordinary union to be represented by 1, that risk will be equal to 18 in marriages between cousin-germans, to 37 in mar- riages between uncles and nieces, and to 70 in marriages between nephews and aunts."£ That hereditary predisposition has a very small share in the production of deaf-mutism is shown by the fact, that the hereditary transmission of the infirmity is the exception, not the rule. Nay, more: " Usually, and in the immense majority of cases, deaf and dumb men married to deaf and dumb women have children who can hear and talk. This is, a fortiori, true in cases of mixed marriages, that is, when only one of the parents is a deaf mute."§ Such was Meniere's opinion, whose authority on such matters is not to be disputed. " Deaf-mutism," says Dr. Boudin again, " is not always directly brought on by intermarriages; it is sometimes produced indirectly in cross-marriages, in cases of perfectly healthy individuals, free from all infirmity, but one of whom was the issue of an intermarriage." * " Annales d'Oculistique," Avril, 1861 (quoted by Dr. Boudin, p. 55). f Boudin: op. cit., pp. 54, 55, 56, 57, and 58. j lb., p. 80. | Pr. Meniere: " Recberches sur la Surdi-Mudite " (Gazette Medicale de Paris, 3e serie, t. 1, p. 243). 774 ON EPILEPSY. In support of this statement the author quotes the following case bor- rowed from a thesis by Dr. Chazarain :* "Mr. L , the mayor of C (Dordogne) married his cousin's daugh- ter, by whom he had a son and a daughter not only free from all infirmity, but also enjoying excellent health, like their parents. Miss L , in her turn, married a young man, a few years older than herself, to whom she was not in the remotest degree related, and gave birth to a daughter afflicted with congenital deaf-mutism. The parents of the child reside in a dry and healthy locality, high above the level of the sea, and their means allow them to live in easy affluence. There is no other case of deaf-mutism at C , nor has there been another case in the family. Lastly, the mother's pregnancy wras not marked by anything special." Now, might not what applies to deaf-mutism in this case be applied also to all the fatal consequences of intermarriages ? A merchant in Paris marries his first cousin; his sister also marries a first cousin, but belonging to another branch. The sister has no children; the brother has three daughters, perfectly formed and in excellent health. Of these three girls, the youngest, seven years younger than the second daughter, has three well-formed children. The second girl has only one, however much she desires to have many; and the eldest, married for more than ten years, remains sterile, to her extreme chagrin. These facts, especially the last, are of doubtful import, I admit; but were they to be found more frequently, now that careful inquiries are made into everything bearing on the question of intermarriages, they would become of some value, and on this account the most insignificant deserve to be noted. To conclude this digression, it has never been said that unions between near relatives were necessarily and fatally followed by evil consequences. Medical observation proves, however, beyond doubt (agreeing in this with the experience of legislators, who in a great many countries have, on that account, proscribed marriages of consanguinity), that the bad results which we have enumerated above, are relatively much more frequent in indi- viduals born of intermarriages, than in those born of mixed marriages, and that both in man and in the lower animals which have been largely experi- mented on ; " intermarriages endanger the species through the sterility, the infirmities, and diseases, which may affect the issue of such unions, when fruitful; and in the case of man, such marriages, when repeated during several generations, bring on physical, moral, and intellectual degeneracy, and, finally, the extinction of the family." Such is Dr. Chazarain's opin- ion, and a great many physicians concur with him. The fatal influence of intermarriages is a frequent cause of mental dis- eases. Esquirol, and after him, all writers on mental diseases, have pointed out that in many cases idiocy and mental alienation had resulted from unions between near relatives. Epilepsy is another of these results. Among others I will relate to you the following instances. I once at- tended the family of a Neapolitan gentleman who had married his niece. There was no hereditary taint, and yet of his four children, the eldest, a girl, was very eccentric; the second, a boy, was epileptic; the third was of perfectly sound mind; whilst the fourth was epileptic and an idiot. A friend of mine, who also married his niece, had four children, one of * L. T. Chazarain: " Du manage entre consanguins, considers comme cause de degenerescence organique, et particulierement de surdi-mudite congenitale." These de Montpellier, 1859. ON EPILEPSY. 775 whom was seized at birth with grave convulsions, and another son is epi- leptic and an idiot. Not long ago, I saw with Messrs. Moynier an epileptic boy, the son of first cousins; and shortly afterwards I had the opportunity of observing two analogous cases, one that of a young man, aged 32; the other, that of an idiotic child, subject to epilepsy. Now that I carefully inquire into the question of consanguinity, when- ever I see deaf and dumb individuals, idiots, and epileptics, I can scarcely tell you how great a share this influence seems to me to possess in the causation of these affections. § 5. Diagnosis between Epilepsy and Eclampsia.- Transformation of Eclamp- sia into Epilepsy.-Differential Diagnosis from Hysteria.-Symptomatic Epilepsy.- Treatment of Epilepsy. Of all convulsive disorders, Eclampsia is the most difficult to diagnose from Epilepsy. These two affections are frequently confounded together, as I have told you already, and this confusion is unavoidable, if we only take into account the convulsive phenomena which characterize them both. Look, for example, at a woman, seized with eclampsia, in the eighth or ninth month of pregnancy, or during labor; see a child in convulsions, either at the outset of an eruptive fever, or during the period of teething; and however much you may be forewarned, however careful you may be in observing the case, you shall not be able to discover any difference between those attacks and the convulsive form of epilepsy. Recall to mind an attack of eclampsia occurring in a pregnant woman, for instance, who is suddenly seized with convulsions, sometimes after having first uttered a loud cry. Her limbs are distorted, on one side chiefly, her head inclines to one shoulder, whilst her face is turned to the opposite side; her tongue is thrust out of her mouth, and may be wounded, cut, or lacerated by her teeth ; froth, tinged with blood, soils her lips and cheeks, exactly as in an individual who has an epileptic fit. The convul- sions last from one to two minutes, and are succeeded by apoplectiform stupor, as in epilepsy again. But we shall be enabled to distinguish eclampsia: first, by the usual recurrence of the seizures, these following one another pretty rapidly; secondly and chiefly, by the circumstances under which the attack comes on; and thirdly, by certain phenomena which precede and accompany the seizure. Whereas epilepsy, when it assumes the convulsive form very distinctly, recurs at pretty distant intervals-(I, of course, set aside the status epilep- ticus)-at intervals varying generally from a year to six, three, and two months, or a week only: eclampsia, on the contrary, runs a more continu- ous course, recurs at very short intervals, and is always imminent so long as the cause on which it depends persists in full force. On the other hand, when once this cause is removed, the recurrence of the convulsions is in general no longer to be feared, whilst a first attack of epilepsy is always a reason for suspecting others, and almost fatally mortgages the future. In a pregnant woman, for example, or a woman in labor, eclampsia may recur from eight to twenty times in the twenty-four hours; thus resembling, in some measure, the status epilepticus I spoke of just now. The patient is not yet out of one attack before she has another, the convulsions beginning even while she is still in the state of stupor characterizing the second stage. The same thing happens in infantile convulsions. The attacks succeed one another rapidly, and when they do not consist in extensive muscular 776 ON EPILEPSY. movements, the phenomena described under the name of inward convulsions, and which are, to some extent, the analogues of epileptic vertigo, are mani- fested for two or three days in succession. There is rolling upwards of the eyeballs, or distortion of the face, or spasm of the respiratory organs, causing momentary interruption of the respiration, which, after a few seconds, goes on with the same regularity as before. This frequency of repetition and continuity of the attacks are a frequent cause of death, which is then due to the commotion of the nervous centres caused by the convulsions, or to asphyxia brought on by the tonic con- vulsions persisting for too lengthened a period in the respiratory muscles, and thus interfering with the oxygenation of the blood. You understand, therefore, how it happens that death is much more fre- quently an immediate consequence of eclampsia than of epilepsy. It very rarely happens, indeed, that an epileptic is carried off in an attack, setting aside those cases of accidental death, the result of grave and fatal injuries sustained in his fall. It too often happens, on the contrary, that women die of eclampsia, and still more frequently that children are carried off by convulsions. What I said just now of eclampsia, occurring in a pregnant woman, or of infantile convulsions, applies equally well to saturnine eclampsia, and to eclampsia depending on albuminuria. Nothing, as far as regards the form of the convulsions, distinguishes them from epilepsy. They are pretty distinctly separated from it, however, by the frequent repetition and the continuity of the attacks; this being the rule in eclampsia, and the excep- tion in epilepsy. The latter affection particularly differs also in that, in the vast majority of cases, it strikes an individual in the midst of the most perfect health. Nothing announces the attack ; a minute before it occurs, whether preceded by an aura or not, the patient was as well as a week before. This is the rule, and the exceptions to it are much more than real, generally occurring in cases of symptomatic epilepsy, which, strictly speaking, should not be separated from eclampsia. Eclampsia, on the contrary, only supervenes under certain given cir- cumstances, more or less easily discoverable. It is dependent on a patho- logical condition characterized by other symptoms, and shows itself at the onset, in the course, or towards the termination of, some acute or chronic disease, and frequently it is even possible to foresee it. Thus albuminuria, whether idiopathic, or due to Bright's disease or to antecedent scarlatina, or whether occurring in a pregnant woman (in the two latter conditions particularly), makes us dread the possible occurrence of eclampsia. After this has shown itself, independently of the other general or local symptoms which belong to albuminuria, the mere presence of albumen in the urine sufficiently indicates the disease. In some cases, of course, this diagnosis cannot be made, as when individuals, that were previously subject to epi- lepsy, are seized with eclampsia. Thus again, in cases of convulsions oc- curring in a child who is teething, or who is at the beginning of an acute febrile affection, you will at once recognize eclampsia, or at least epilepsy will occur to you on second thought only. Yet, gentlemen, some reserva- tion should be made. These eclamptic convulsions, whatever their exciting cause may have been, are often indeed true epileptic fits. It is especially in children above five or six years of age, and even in younger children, that epilepsy may be dreaded for the future, when the attacks of eclampsia occur frequently and for the least thing. I have sometimes also seen epi- lepsy in women who at some more or less distant period had been seized with eclampsia during labor. I have always asked myself whether there ON EPILEPSY. 777 may not be some connection, in such cases, between eclampsia and the epi- leptic fits, and I have felt inclined to answer the question in the affirmative. These considerations, in cases of infantile convulsions, apply particularly to that form of partial convulsion which affects the muscles of the larynx, and has been very improperly called thymic asthma. You saw an instance of this some time ago in a baby eight months old, whose health was very good in other respects. His mother said that frequently, whether he was at the time sitting in his crib, or was being nursed in her arms, he suddenly uttered a loud cry, as if he felt acute pain. This cry resembled that of a fit of anger, but was immediately followed by a noisy, hissing inspiration, similar to that of hooping-cough. The face was red, the veins of the neck were swollen. After a few seconds, however, the child became calm again, and recovered his previous condition; He had also suffered from regular convulsive attacks. In such cases-and I shall some day revert to this point, which is of the highest practical importance-be very reserved in your prognosis. Although these symptoms be not serious in general, the patient's life may, however, be in immediate danger when the laryngeal spasm is prolonged beyond a certain period, for, if it lasts two minutes, asphyxia is produced. Moreover, I repeat, these partial convulsions may be a manifestation of epilepsy, which, sooner or later, is attended with more distinct and more character- istic phenomena. I next pass on to the differential diagnosis between Hysteria and Epilepsy. This is, in some cases, attended with great difficulty, as I have already pointed out. Thus, although in general preceded by very characteristic nervous symptoms, a convulsive attack of hysteria may sometimes set in suddenly, or the patient may, at the beginning, have felt a kind of aura, a spasmodic sensation, which, starting from some point of the body, becomes general, and bears some resemblance to the aura epileptica. I hasten to add, however, that such cases are exceptional. In the great majority of instances, hysterical convulsions are ushered in by phenomena which, when once observed, can no longer be mistaken. As to the aura hysterica itself, it differs widely from the aura epileptica. I have already drawn attention to the fact, but it is of such importance that I do not fear to revert to it. The aura hysterica starts almost constantly from the same point, and is compared by the patient to the sensation of a foreign body, of a ball press- ing on the umbilical and epigastric region, and which, extending upwards along the oesophagus, produces, on reaching the throat, a feeling of chok- ing. However short may be the time during which this sensation lasts, it persists generally much longer than the aura epileptica, the rapidity of which may, in almost all cases, be compared to that of lightning. Another important point is, that hysteria affects the female sex almost exclusively, so that the fact of a patient being a female should put you on your guard, and make you suspect the nature of the symptoms. The aspect of hysterical persons is besides very different from that of epileptics. As to the attack itself, it is tumultuous in hysteria, more silent in epilepsy. An individual in an epileptic fit, is convulsed for a few moments, but after a few seconds he becomes motionless and passes into a state of stupor; the deadly pallor of his face is replaced by redness, of a more or less livid, bluish tint. Hysterical convulsions are, if I may use the expression, more demonstrative: they consist in extensive movements, which do not affect one side especially, as in epilepsy, but both sides nearly equally, except in cases complicated with catalepsy or paralysis. The patient can be restrained by several persons only. If an epileptic be seized whilst lying down, he remains in his bed; if whilst standing, he falls down, 778 ON EPILEPSY. and rarely quits the place where he fell. An hysterical patient, on the contrary, throws herself about in all directions; if in bed, she rises and throws herself to the right and to the left. An epileptic, again, after having uttered the cry which generally precedes a fit,remains silent; an hysterical woman keeps crying during the attack, and goes on moaning, or, towards the close, bursts into tears or into a laugh, without any reason. Lastly, whilst a fit of haut-mal rarely lasts three minutes, hysterical con- vulsions are prolonged for a much longer period. Such are, speaking very generally, the distinctive characters between an epileptic seizure and an hysterical fit. As to the fundamental differences between the two diseases, I need not insist on them now. There are cases, however, gentlemen, in which the symptoms observed are really on the confines between the two diseases. You may remember a nurse who was formerly in my female ward, and who is at present at the Salpetriere. She was certainly hysterical, but her attacks sometimes pre- sented, at the onset, the characters of epileptic seizures. You could see at the same time, and in the same ward, that young girl whose history I have already related to you, and who, during her epileptic fits-which lasted, it is true, one minute only-was frequently agitated with the same violence and the sort of jactitation which belong to hysteria. Let me add again (and there are pretty numerous instances of this at the Salpetriere) that some women are at the same time hysterical and epileptic ; and, indeed, there is no reason why epilepsy should protect against hysteria, or vice versa. I now proceed to the consideration of another point as regards the diag- nosis of epilepsy. An individual, with a tumor of the brain, of tubercular, syphilitic, or cancerous nature, is seized with convulsions-should they be called epileptic? A great many physicians will reply in the affirmative, but will add the qualification of symptomatic to the name epilepsy. It is true that these epileptiform convulsions differ in nothing from those of genuine epilepsy, but the seizure is sometimes preceded by more or less violent headache, which is exactly localized by the patient. Sometimes also, there exists more or less complete paralysis, limited to one side of the trunk, the muscles of the face, the eyes, the soft palate,-a paralysis of movement to which is, in some cases, superadded a paralysis of sensation; lastly, there may be also impairment of the intellect. Now all these symptoms indicate the existence of some more or less profound organic lesion of the brain. The following case is a remarkable instance of this, and, although it was one of the first of the kind which came under my observation, and although more than thirty years have elapsed since then, I still remember it perfectly. A gentlemen was one evening, for the first time in his life, seized with epilepsy whilst at the British Embassy. Shortly after this he had a second attack, and on one occasion, whilst riding in the Champs-Elysees, he fell down from his horse in a fit, and severely injured his head. From that time he gave up going into society, and consulted Dupuytren, who prescribed, but without success, the remedies vaunted against epilepsy. He next placed himself under the care of Dr. A. Lebreton, who, on carefully inquiring into his previous history, ascertained that he had suffered from violent and chiefly nocturnal headache. I was then asked to meet Dr. Lebreton in consultation, and we together made out that the pain was almost exclusively limited to one side of the head. The periodical recurrence of the headache and its nocturnal exacerbation pointed clearly to syphilis; and indeed, we ascertained on inquiry that the patient had had a venereal affection five or six years previously, to which he had never paid attention. Suspecting, ON EPILEPSY. 779 then, an intracranial exostosis, or a syphilitic tumor, we recommended a treatment chiefly consisting of Liq. Van Swieten. The symptoms disap- peared completely from that time, and a radical cure was obtained. This case, then, was one of epileptiform convulsions, or of eclampsia, to use the expression which is current in the profession, but it was certainly not a case of epilepsy in the sense usually meant. In some cases the form of the seizure resembles epilepsy still more closely. Last year I was consulted by a lady 71 years old, who, since the age of 40, had been subject to attacks recurring with a daily increasing frequency, and so much so that she had as many as twenty-one in the twenty-four hours. The diagnosis of her case was written in large type on her face, for she had on the forehead a broad, deep scar, which began above and outside of the right eyebrow, and penetrated the frontal bone, which had necrosed. There had also been necrosis of the nasal bones, for the nose was broken down and depressed. Under the influence of mercury and iodide of potassium, rapid improve- ment followed, so rapid indeed that she had only one attack in the very first month, and this proved the last. In some cases, the lesion which is the exciting cause of the attacks is so trifling, that its importance is with difficulty suspected. Dr. Foville saw, with Alph. Robert, my excellent colleague at the Hotel-Dieu, a young notary's clerk, who, for several years, had been subject to monthly attacks of epilepsy. Many remedies had been tried in vain, when Dr. Foville suggested the extraction of some carious teeth which ached constantly. The suggestion was acted upon, and from that day the fits disappeared. On March 2d, 1861, Dr. Monnier, of Saint-Paul (Eastern Pyrenees), communicated to me a no less interesting case, which somewhat resembles the case of Graves which I quoted a short time ago. A man 40 years old, tall, and of a robust constitution, was seized on several occasions, and at very short intervals, with violent epileptic attacks. Dr. Monnier, on learn- ing that the patient often passed fragments of taenia, gave him large doses of castor oil. A whole taenia came away, and from that time the convul- sive attacks ceased. The little success which attended the treatment of epilepsy had, among the ancients, obtained for it the appellation of morbus sacer, a scourge sent by the gods in their anger. The unfortunate patient was fatally doomed to convulsions, and nothing short of a special intervention of the gods could save him from the fate which awaited him. The progress of science has little changed matters in this respect, and epilepsy is, in general, as incurable now as formerly. I say in general, and I make this reservation, because there is no medical man, of large experience, who has not seen some epileptics get well. You shall have occasion also to see a certain number of patients remain seven, eight, ten years, and more, without any fresh fits, although these recurred frequently before. Now, in a complaint of this nature, a long truce looks very much like a cure. When a disease admits of so fatal a prognosis, the number of remedies vaunted for its cure increases indefinitely. And as, in some rare cases, a spontaneous cure takes place, the credit is given to the treatment, and not to nature, until repeated failures show the inefficacy of the remedy. Epilepsy could not escape the common law. Its incurability necessarily led medical men to use against it all the resources of their therapeutic arsenal, so that known drugs, as well as unknown remedies, some appar- ently rational, others empirical, others again of the most extraordinary character, were tried in succession. And it would be difficult indeed to give a complete list of all the remedies which have in turn been vaunted 780 ON EPILEPSY. against epilepsy, and soon justly given up, beginning with those mentioned by ancient authors, some of which were abominable, and invented by super- stition, " qucedam satis abominanda," and " superstitiosa plurima" and not forgetting those of which ignorance and bad faith dare exaggerate the vir- tues, even to this day. Is medicine, then, entirely powerless against this terrible disease? Not completely so,-for there is a mode of treatment, the treatment by belladonna, which, if it cures epilepsy in very rare cases only, procures at least a pretty large number of patients a real alleviation of their sufferings. Although, from the difficulty we have of judging of its effects, the same objections apply to this treatment as to all the rest, yet skepticism should not go beyond certain limits, and we cannot refuse to believe the testimony of grave physicians. Long ago, according to Murray, Greding had several times administered belladonna-either in the form of powder or of extract -to patients afflicted with simple or complicated epilepsy ; and if they did not get well, they improved remarkably at least. These observations were confirmed by Leuret at and by Ricard ; but it is Bretonneau who, in our time, has handled this remedy with the greatest perseverance and success. Almost simultaneously with the illustrious physician of Tours, Father Debreyne, physician to the Trappe of Mortagne, and a Trappist himself, obtained similar results. As to myself, I have employed it for more than thirty years, and it has seemed the least inefficacious of those I have ever tried or seen tried. Indeed, I can now count a certain number of real cures, and in many cases I obtained an improvement which I dared not expect. Above all, an essential point must be laid down, namely, that the remedy is to be trusted only in so far as it shall be administered in accordance with certain rules; which should not be infringed. There is a great principle in therapeutics, which should not be forgotten here, less than ever: it is this, that when a disease has deeply penetrated the organism, when it masters its whole substance as it were, one cannot pretend to silence its manifesta- tions, to cure it within a short space of time. A chronic disease requires chronic treatment. Thus, when syphilis dates five, six, eight, ten years back, you cannot hope to cure it, except on condition of subjecting the patient to a very prolonged treatment, for five or six months at first, and, after a short interruption, resuming it again, and so on for several times. On this condition alone will you succeed in rooting up the evil, and in removing it entirely. , Now, if syphilis requires such prolonged treatment, how much more must epilepsy require it, the germ of which often exists in the system from birth ? The treatment should be persevered in, therefore, not for months only, but for several years in succession. The disease is to be allowed no truce, and the system should be kept constantly under the influence of the drug, lest it should be mastered again by the disease which is forcibly kept down. Of this, gentlemen, you should be firmly convinced, and of this you should warn the patient who places himself under your care, and his friends who ask your advice. Let us see, then, how belladonna should be administered. Pills are made up according to the following formula : R. Extract! Belladonnas, Pulv. Fol. Belladonnas, g''- 5 aa pro pil. j ; mitte 100 similes. During the first month, the patient takes one of these pills every day, in ON EPILEPSY. 781 the morning, if his attacks occur chiefly in the daytime ; or in the evening, if they are chiefly nocturnal. One pill is added to the dose every month; and whatever be the dose, it is always taken at the same period of the day. By that means, the patient may reach the dose of from five to twenty pills, and even more. It is impossible to say beforehand what should be the maximum dose; this depends only on the toleration of the drug by the patient, and its influence on the disease. Excessive dilatation of the pupils, and very uncomfortable dryness of the throat, indicate toxic effects, beyond which the drug should not be pushed. If the belladonna is borne with very great difficulty, the dose should be increased only every two, three, or four months. When an improvement seems to show itself, the last dose given is con- tinued for some time, and it is then gradually diminished. Lastly, all treatment is suspended for a time, and is resumed again, after an interval the duration of which should be proportionate to the degree of improve- ment. I cannot too much impress upon you that patience, both in the physician and the patient, is the principal condition of success. A year sometimes is scarcely sufficient for discovering the influence of the belladonna; and if in the succeeding year some improvement follows, the treatment is to be persisted in for two, three, and four years, according to the rules I have laid down, in order completely to master the nervous system. For some years past I have used atropia in preference to belladonna. I prescribe it as follows : R. Atropiae sulphatis, 1 grain. Spiritus vini gallici, 100 minims. One drop of this solution, that is to say l-100th of a grain of atropia, is given instead of one of the above pills, and the dose is increased by one drop for every succeeding month. Although this treatment, I repeat, has appeared to me the least ineffica- cious, yet, in the majority of cases, I must confess it, I have seen it fail completely. Belladonna, therefore, is far from being a specific against epilepsy ; but it is more valuable than the preparations of silver, of copper, and of zinc, although, when it has proved ineffectual, I sometimes use these with some benefit. In most cases I combine these various remedies. Thus, I give belladonna in the morning, and nitrate of silver in the evening, ten days running, every month. I prescribe the following pills : R. Argenti nitratis, gr. ij. Pulveris acaciae, Aquae destillatae, q. s. pro pil. x. Even to a child, between four and ten years old, two of these pills are given every day. For the next ten days I replace the nitrate of silver by copper. R. Cupri sulphatis, gr. xx. Sacchari, gr. lx. Misce et divide in pulveres xx. The patient takes at first two of these every day, and he gradually increases the dose to six, always, of course, taking care that the stomach tolerates the drug. In the case of a child, each powder should contain only from £th to |th of a grain of copper. For the last ten days of the month, I again replace the copper by prep- 782 ON EPILEPSY. arations of zinc, given in pretty large doses. I give the lactate of zinc, associated with sugar, as in the preceding formula, so as to give it in a powder, or in pills made up with confection of roses. The dose is from two to eight grains. After this, I return to the nitrate of silver, then to the copper, and next again to the zinc. Such, gentlemen, is the treatment which I habitually recommend. You will obtain more favorable results from it in the convulsive than in the vertiginous form of epilepsy. Petit-mal is indeed considerably more intrac- table than grand-mal. Quite recently, my excellent friend, Dr. Henry Gueneau de Mussy, has stated positively to me that he had been remarkably successful in the treat- ment of epilepsy by bromide of potassium. On the ground that modifications of the circulation often produce cor- responding modifications of innervation, Dr. Duclos (de Tours) thought of treating epilepsy by digitalis, which so powerfully modifies the functions of the circulatory system. In a certain number of cases he has seen weekly or monthly attacks diminish in intensity, and even delayed for a period of twenty-seven months. He has also known epileptics thus treated be at- tacked again only five and even seven years after they had ceased the treat- ment. He gives the hydro-alcoholic extract of digitalis in pills containing each one grain of the extract. The first day he gives one pill only; the second, two pills, one in the morning, the other at night; on the third day three pills, one in the morning and two in the evening; on the fourth, four pills, two in the morning and two in the evening; and lastly, on the fifth day, two pills in the morning and three in the evening. He continues in this way until a sensible effect is produced on the circulation, as generally happens after twelve days or so. He then suspends the treatment for ten days, after which he begins it again, increasing the doses gradually, and then withholding the drug again for some time. He continues in this way for a lengthened period, taking care, in proportion as the treatment is pro- longed, to increase the intervals of rest from ten to twenty, thirty, and forty days, ceasing at last after ten months. I have gone into all these details, gentlemen, because the art of administering the drug has an important share in the good results obtained from this method of treatment, and be- cause the physician who has praised it, is one of the most skilful represen- tatives of the great school of Bretonneau. I told you that some individuals had warnings of a returning fit in a peculiar sensation constituting what has been termed the aura. Cases have been reported by most trustworthy authors, in which the fit was prevented by firm compression applied between the starting-point of this aura and the nervous centres, when the aura began in a limb. Ingenious contrivances have even been invented for facilitating the application of this firm com- pression. Thus, an instrument-maker made for a young epileptic, who had an aura starting from the thumb, and from there ascending along the arm to the head, a kind of leather bracelet with straps, which could be quickly slipped round the wrist, and tightened with considerable force. I shall not say much of the surgical means employed, some of which appear to me, at the very least, useless. Thus, not only has the actual cautery with the red- hot iron been proposed along the course of the nerves which the aura was supposed to follow, but castration even has been suggested in the cases where the aura seemed to start from the testicles. Nay more, a singular theory has been broached which has been called the theory of laryngismus, according to which epilepsy is said to be caused by occlusion of the glottis, owing to spasm of the laryngeal muscles. Hence, say the authors of this theory, if a passage to the air be opened up, which cannot be closed by the convulsed ON EPILEPTIFORM NEURALGIA. 783 muscles, all the symptoms will disappear, and they, therefore, have recom- mended as a " very simple remedy "...." tracheotomy." If they do not pretend to cure epilepsy, they at least pretend to ward off the attacks, and to do away with the dangers consequent on them. I should not have spoken of this savage method, if it had not, of late, had a certain amount of vogue. But whilst mentioning it here, only to stigma- tize it, it would be insulting you if I thought it necessary to seriously dis- cuss the subject, in order to prove to you the absurdity of so strange a theory, and the barbarity of a measure which no true physician will be tempted to employ. LECTURE XLII. ON EPILEPTIFORM NEURALGIA. The Branches of the Trigeminal or Fifth Cranial Nerve are those generally Affected.- The Neuralgia is in most cases Accompanied by Partial Con- vulsions.-Is nearly Incurable.-Analogy between it and the Aura Epi- leptica.-Differs from Epilepsy, although sometimes Observed in Epilep- tics.-Is Relieved by Section of the Nerve and by Large Doses of Opium. Gentlemen: Epileptiform neuralgia presents two varieties. One of these, and the more common of the two, is characterized by neuralgic pain, unattended with convulsive twitches. The other form is accompanied by convulsive movements, and I designate it tic douloureux, in order to dis- tinguish it from what is generally and justly understood by tic. This latter is a kind of chorea, although in other respects very distinct from St. Vitus's dance, and is a convulsive affection, unattended with pain, which you have often had occasion to see. It consists in rapid, transitory, and involuntary movements of the face, the neck, or the limbs, and which vary indefinitely. Tic douloureux, on the contrary, and the non-convulsive form of epilepti- form neuralgia as well, always occupy the same seat, or until now, at least, I have only found them affecting the branches of the fifth cranial pair. An individual who, but a moment ago, was perfectly free from pain, is suddenly seized with horrible pain whilst talking. He puts his hand up to his face, and presses it with considerable force, sometimes rubbing it so much and so often that the hairs on that side fall of. (I allude, among others, to the case of that man who has been so long in my clinical wards, and to whose history I shall again revert.) He goes on rocking himself, holding his head between his hands, and uttering half-suppressed groans. This scene lasts for ten to fifteen seconds, one minute at the most, and all is over then without convulsions. The individual resumes his interrupted conversation, until a fresh paroxysm sets in again. This is what I mean by simple epileptiform neuralgia. In another case, simultaneously with the accession of pain, all the mus- cles of one-half of the face are seen to be thrown into rapid convulsive action, and the attack, as in the preceding case, is over in about a minute. This is convulsive epileptiform neuralgia, or tic douloureux. Like everybody else, I used to confound epileptiform neuralgias with all the cases in which pain is felt along the branches of the fifth pair, and 784 ON EPILEPTIFORM NEURALGIA. which are comprised together under the common appellation of trifacial neuralgia; but a few years of practice sufficed for showing me their nature. Whilst the latter were generally of no gravity, and yielded, some of them spontaneously after a few hours or a few days, and others under the in- fluence of proper general or local treatment, I soon found out that the former resisted with a disheartening obstinacy all therapeutic measures, so much so, indeed, that even now, after more than thirty-six years of prac- tice, I have never known it to be cured in a single case radically. I was not long before noticing that this form, which was amenable to no method of treatment, ran the same course as epileptic aura or vertigo, hav- ing the same suddenness of invasion, lasting the same length of time, and being especially like them almost incurable. When I compared it with epileptic vertigo, whether or not preceded by a painful aura, and with epi- leptic fits beginning in one limb and remaining exclusively limited to it, or again with angina pectoris, I could not but be struck with the analogy and the points of resemblance between these various neuroses. The first case in which I studied this strange neuralgia was that of a man who, in 1831, occupied a bed in the St. Bernard Ward, at that time a male ward. I was then physician to the Bureau Central des Hopitaux, and as such was acting as the substitute of my illustrious master, Professor Recamier. I had the honor of having for my house-physician A. Bonnet (of Lyons), whose premature death science now deplores. This poor patient, w7ho filled some post at the Saint Antoine Hospital of Paris, had for many years been subject to the convulsive form of neuralgia. His paroxysms lasted sometimes a few seconds only, and sometimes a minute; they recurred whenever he spoke, drank, or ate, or whenever one touched with the tip of a finger the few teeth which he had left. The pain w7as seated in all the branches of the trifacial nerve of one side, but chiefly in the infraorbital division. Several of the nerve-trunks had been divided already; but the relief had only been temporary, and the pain had always obstinately returned after an interval of from a few weeks to a few months. The extraction of his last remaining teeth gave him no relief. Prolonged applications of a solution of cyanide of potassium did some good. But the pain still returning, as awful and as unbearable as ever, I decided upon dividing the infraorbital branch. Bonnet performed the operation with great skill; the patient was relieved instantly, and remained free from pain for several months. The following year, I saw7 him again, suffering in the same way in the course of another nerve of the face, and with the same convulsions. Professor Roux, as far as I can remember, again divided several nerves. Lastly, in 1841, Dr. Piedagnel saw7 in his wards at La Pitie this same individual, whom he had known thirty years previously, w7hen house-physician at the Saint Antoine Hospital. The poor man's face was scarred from the surgical operations which he had undergone, for when- ever the pain became intolerable, he implored the help of the knife, for this at least gave him relief for a few days, and sometimes a few7 months. About the same period I saw7 in the Marais quarter a lady 50 years old, who for twenty years had been subject to this epileptiform neuralgia of the face. She had from ten to a hundred attacks a day, but sometimes passed a day, a w7eek, or even a whole month without a paroxysm. The convul- sions lasted only a minute at the most, and were confined to the left side of the face ; the pain was described as awful. A little relief w7as obtained by compressing the face with both hands, and this compression, so often re- peated during so many years, had produced flattening of the left side of the face. The lower jaw and the malar bone had been, as it were, squeezed dowm. Dr. Lebaudy divided the temporal branch of the trigeminal nerve, ON EPILEPTIFORM NEURALGIA. 785 and temporary relief was thus given. But the pain afterwards returned with renewed violence in the other branches which had formerly been less affected. This sad complaint persisted until the lady's death. In 1846 I saw in my consulting-room a gentleman of about 55 years of age. He had no sooner sat down near me, than he suddenly got up as if moved by springs, and rapidly raising his hands to the right side of his face, which was convulsively distorted, he paced about the room, stamping his foot with a sort of rage, moaning, and groaning like a madman. This strange scene lasted about a minute, and he then sat down. Before he uttered a word, I told him that I knew what he suffered from, and that although I might relieve, I could not cure him. He thanked me for being so candid, and then informed me that he had been, for more than twenty years, subject to this hateful neuralgia, which had always affected the same nerves, and which after disappearing for a few days, and sometimes a few months, returned with a hopeless obstinacy, defying the most varied and energetic treatment. Six years afterwards I saw him again; he was still in the same state, for he had refused to try the palliative treatment which I had recommended, and of which I shall tell you presently. At this mo- ment, gentlemen, you can see a similar case in St. Agnes Ward. You must have been struck with the look of suffering stamped on his face. Although he is only 48 years old, his face is deeply wrinkled, in consequence of the contractions by which its muscles are almost continually agitated. He relates that he has always been subject to toothache, but that for the last four years the pain has become so intense that he has been compelled to consult a medical man. Flying blisters, and some pills of which he does not know the composition, calmed the neuralgia for a short time; a year afterwards he came to Paris, and was admitted into Bieetre. Whilst there he was treated with flying blisters, dressed with morphia. He next went to the Pitie Hospital, for, apart from his habitual neuralgia, he had inter- mittent fever, which was cured by quinine, without the slightest modifica- tion of the neuralgia. Eight months later he was a second time readmitted there, and was treated by my colleague, Dr. Marotte. Quinine and iodide of potassium in large doses, blisters dressed with morphia, sulphur baths, faradization, cauterization with the red-hot iron of the cheek and forehead, gave no relief. Two months afterwards he came here. I at once tried the effect of nar- cotics in large doses, which in analogous cases had seemed to me to be of great utility. I prescribed for him the aqueous extract of opium, and be- gan almost at once with ten grains taken in the twenty-four hours, gradu- ally and rapidly increasing the dose to half an ounce. Within a few days relief was obtained, and four or five mouths afterwards he felt so decidedly better that he wished to be discharged. This amelioration did not last long. For three months the man had only a few slight attacks of pain, and he could drink, eat, sleep, and resume his occupation as a copper-turner, but the pain then returned with its former intensity. He was readmitted into my wards, and, after being treated in the same way as before, he left markedly relieved. Last year, however, he returned to the Hotel-Dieu, and was admitted into another physician's ward, where he was treated in the same way again. This time, the pain being less acute than before, the opium had not to be given in as large doses. Since then he was free from violent pain; but in April, 1860, the pain having returned with its former intensity, he was for the third time admit- ted into St. Agnes Ward, which he now wishes to leave, feeling quite well again. vol. i.-50 786 ON EPILEPTIFORM NEURALGIA. With regard to his previous history, he affirms that he has never had syphilis. The only grave disease which he has ever had, is an attack of copper colic, which for a short time compelled him to give up his trade. He also had intermittent fever of short duration. As to his family history, he states that he is not aware of any instance of nervous disease among his relations. Independently of his paroxysms of pain, he says that he constantly ex- periences, in the affected side, an unpleasant sensation, which he compares to the oscillations of a pendulum, followed by seven, eight, ten, fifteen par- oxysms of excessively acute pain, within the space of five minutes. This pain starts indifferently from three constant points, which he indicates per- fectly, namely, the points of emergence of the trigeminal nerve, and is ac- companied by spasmodic contraction of the muscles of the face. It is fear- fully intense, and drives him to squeeze the affected part violently, and to rub it with a kind of rage. This relieves him a little, but it has been repeated so often that the hair has fallen off from that part. The attacks recur day and night: moral emotions, passing from a warm into a cold place, or the reverse, excite them, and they are more frequent and more violent in damp weather or during atmospheric changes. They are gener- ally accompanied by a more abundant secretion of urine. This almost con- stant pain kept the poor man in a state of perpetual fear; his intellect, how- ever, has not been in the least impaired, and his memory is perfect. A remarkable circumstance is, that when he has been cured by the prolonged use of opium, he is warned of the return of his attacks by pain in the loins, by an increase of saliva (particularly in winter), and by an eruption of prurigo, chiefly on the back, attended with distressing itching. His neu- ralgia has always occupied the same seat. His senses are perfect, but read- ing, if a little prolonged, brings on a paroxysm. Chewing anything hard also brings on an attack. His speech is embarrassed, but it is only because he dares not move his mouth and throw the muscles of the face into con- traction, lest he should rouse the pain. His appetite ancT digestion have been good always. On this, as on previous occasions,' I gave him opium in large doses, and under its influence the same amelioration was obtained. In some cases, the neuralgic pain, after gradually becoming less and less, disappears for two, three, or four months, and when the patient thinks himself cured, re- turns with renewed intensity, for the space of a few months, and even a year. Very recently I was consulted by an innkeeper of Meaux, sent to me by Dr. Charpentier. He was, at the time, subject to attacks which lasted from fifteen to twenty seconds, and recurred every two or three minutes at the most. When they ceased, as they sometimes did for a period of two or three months, he was perfectly cured, for the inferior maxillary nerve, the usual seat of his pain, was completely insensible. But in the great majority of cases,unfortunately, the relief is not complete, and even when there has been no fresh attack for several months, the patient still complains of a slight degree of pain at the point of emergence of the affected nerve. Whatever be the analogy between true epilepsy and this epileptiform neuralgia, I must admit, however, that the two diseases are merely analogous, not identical; for an individual, subject to epileptic aura or vertigo, rarely escapes an occasional convulsive fit, and it rarely happens, especially, that the intellect be not slightly disturbed during and after the vertigo. Now, in the cases of epileptiform neuralgia, I have never, as yet, found the least impairment of the intellect. Still, gentlemen, a few cases that have occurred in my own practice ON EPILEPTIFORM NEURALGIA. 787 would seem to lead one to believe that, in some cases, epileptiform neural- gia is one of the manifestations of true epilepsy. I once attended a country practitioner suffering from tic douloureux. For many years, we combated this terrible affection with energy, and in the last period of his life the unfortunate man had genuine epileptic fits. At this very moment, Dr. Beylard (formerly my clinical assistant) and I are attending together an American gentleman, who, for more than three years, has been subject to awfully painful attacks of epileptiform neuralgia, and to well-characterized epileptic fits. Perhaps, there has been merely a coincidence in these two cases. But were true epilepsy to be oftener met with in connection with this neuralgia, the two diseases should be lessrseparated than I have done, and a kind of rela- tionship should be admitted between them. I confess that I neglected to inquire into the family history of my pa- tients. But should there be found in this family history, insanity, progres- sive locomotor ataxy, hypochondriasis, &c., epileptiform neuralgia will, perhaps, have to be placed by the side of epilepsy, and both these affections be looked upon as the expression of one and the same cause. Although from its nature, epileptiform neuralgia may be considered as nearly in- curable, I have always thought it my duty to try and combat it by the least inefficacious and the most energetic remedies I had the disposal of. I was besides encouraged by very authentic, although rare, instances in which epilepsy has been cured. The surgical measures, the utility of which I contested as regards the aura epileptica, are sometimes of real service in these cases; and you must at once see the reason of this difference. In the case of an aura, nothing assures us that one nerve is the seat of the sensation instead of another, whilst in epileptiform neuralgia, the seat of the pain can be easily deter- mined. Hence, division of the affected nerves in the points where they can be reached without danger almost certainly gives immediate relief. But I hasten to add that, although I have no hesitation in recommending di- vision of the painful branches of the trifacial nerve, yet I do not expect a lasting good result. Even if I were to see a patient remain better for a pretty lengthened period, I should always dread a recurrence of the disease. I formerly believed, like many others, in the complete efficacy of this meas- ure, but as I grew older, I unfortunately lost all my illusions on that score. In 1836, Mr. N , a clerk at the Finance Office, consulted me for an epileptiform neuralgia, which had its starting-point in the tongue. The aura began first in the left half of this organ ; from there it spread to the lips, and then to the whole corresponding side of the face, accompanied by horrible pain and by slight convulsions. I tried the most powerful stupe- fying drugs. Local applications of extract of belladonna and of stramo- nium, blisters dressed with morphia, the administration of narcotics in very large doses, only produced temporary alleviation; the pain recurred with disheartening obstinacy. I then resolved to divide the lingual nerve, and the operation being somewhat perilous and difficult, I determined to avoid all risks, by proceeding in the following manner: I seized the tip of the tongue, taking care to have a piece of linen between my fingers and the painful organ, and passed through it, from behind forwards, a round and curved needle, carrying a silver wire. I next brought the two extremities of the wire together, thus embracing within the circle the left half of the tongue, and I placed them in a knot fastener, which the patient screwed up every five minutes. The first part of the operation was not very painful, and the gradually increased com- 788 ON EPILEPTIFORM NEURALGIA. pression produced by the tightening of the knot was attended with much less pain than I had feared. Within five hours the left half of the tongue was thus completely divided, without the least hemorrhage. As soon as the compression became a little powerful, all painful aura ceased, and the only pain felt was that due to the gradual division of the organ. When the operation was over all pain ceased, and the patient believed he was cured. For nearly a month the apparent cure was main- tained, and I was congratulating myself on a success, which in truth I had somewhat expected, when in a short time slight shooting pain attacked the upper lip, on the same side, always retaining the epileptiform character, and attended with slight grimaces and jerks, the whole occurring in less than a minute. A few days afterwards the*pain spread to the lower lip, the edges of both jaws, and the infraorbital and mental branches of the trifacial nerve. Although considerably less intense than before, the pain had not the less returned, and for several years it recurred again. The patient then left Paris, and I lost sight of him. My excellent colleague, Professor Nelaton, does not simply divide the nerve, but cuts away a portion of it, about one-fifth of an inch. He has often affirmed to me that by this means he had obtained two sound cures. It is true that two years had not yet elapsed when he informed me of his success. Is it to be said, then, gentlemen, that we can never give relief in such a degree that it may be almost equivalent to a cure ? I confess openly that I have never cured a single patient, none at least of those whom I could see during several years ; but I have made the life of some bearable, as you have yourself seen in the case of the individual who is still in my ward, and whose history I related to you. This is the treatment to which I have recourse; but I must at once tell you that belladonna, which is of some utility against the convulsive form of epilepsy, is almost completely powerless against epileptiform neuralgia, whilst opium procures decided relief: An old lady, from Antwerp, placed herself under my care, in 1845, on account of epileptiform neuralgia of the face, to which she had been subject for more than ten years. At first the pain had been slight, and always transitory, affecting one of the divisions only of the trifacial. Afterwards it had become excessively intense, and had resisted various remedies. The paroxysms lasted from a few seconds to three minutes. Beginning some- times in the infraorbital division, and sometimes in the supraorbital, or the mental, the pain rapidly spread to all three divisions; and when it was at its maximum, it produced spasmodic grimaces of the face. There were sometimes twenty paroxysms in an hour; the least movement brought them on-speaking, coughing, eating, or drinking. In order to diminish the pain she squeezed her face with violence, and moved the skin up and down on the bones. When the pain was more acute, she got up in a sort of frenzy, paced up and down her room, stamping her foot, and uttering muttered groans. This was of such frequent occurrence, that she had become a nuisance to her neighbors, whom she disturbed at night. The pain disappeared sometimes for eight, fifteen, thirty days, and even longer, but then returned with renewed violence. A remarkable circum- stance was, that when the paroxysm was over, the pain ceased entirely, ♦leaving only a sensation of numbness behind. A good many remedies, rational and empirical, had been tried, but without success. Dr. Somme (of Antwerp) divided the infraorbital branch, and thus obtained an apparent cure; but a few months had scarcely elapsed before the pain recurred as before. ON EPILEPTIFORM NEURALGIA. 789 After having given her, methodically and perseveringly, some remedies which I thought had not been thoroughly tried, I knew not what to do in presence of so violent and obstinate an affection. I then determined on administering opium internally as a palliative,- encouraged in the idea by the fact that I had obtained very evident alleviation of the pain, in this case and in others, by dressing blisters with morphia. I first gave morphia internally, beginning with pretty large doses, from 3 to 4 grains a day, and determined on increasing this quantity if the first doses were borne well. I thus came, in less than a fortnight, to administer every day a drachm of sulphate of morphia. The amelioration obtained was immense; scarcely were there, in the course of the day, slight shooting pains felt in the branches of the trifacial. Digestion was slightly disturbed ; the intellect was normal. But a great difficulty now occurred ; the patient's means were limited, and the high price of the morphia almost ruined her. I then had recourse to opium, and in the space of a year she consumed 1200 francs' worth (£48). This was too much again. The pain recurred whenever she omitted the medicine for eight or ten days, and she was again obliged to diminish an expense which she could not bear. I then obtained of a chemist for her crude opium, at trade price, for which she paid 20 or 25 francs (16 or 20 shillings) a pound. She made boluses of a drachm each herself, and of these she took, according to the pain, from 5 to 20 a day. It is rather remarkable that these enormous doses of opium did not dis- turb digestion notably; they caused no drowsiness either, and at night the patient slept as usual. For a period of more than six years I saw this lady from time to time, and I ascertained the following therapeutical results. She was sometimes free from attacks for one, two, or three months; she then suspended the opium, after having first gradually diminished the dose in proportion as the pain itself grew less and the attacks became more distant. On the neuralgia returning of a sudden, with fresh violence, she took, at once, and from the first day, as much as four and five drachms of crude opium, keeping up this dose until relief was obtained. She then diminished it again, because she could no longer take it without feeling nausea and considerable malaise. A few days sufficed for making the pain bearable, I might almost say for curing it, did not slight paroxysms of pain occasionally remind her that she was not cured. By continuing the opium, however, she obtained complete relief for a more or less prolonged period. Opium, therefore, gave immense relief, but did not cure perfectly ; and, I repeat, ever since my attention has been more especially directed to this form of neuralgia, I have never known a case of lasting cure. It is to opium, then, that I have recourse now, and it is opium which I administered to the patient in St. Agnes Ward, increasing the dose in a few days, as you saw, to and even 4 an ounce of the extract. But I often meet with patients who dread so energetic a mode of treatment, and with others who, being troubled with vomiting, cannot bear sufficiently large doses. In the beginning of the summer of 1852 I was, strangely enough, con- sulted on the same day by two old officers, both subject for many years to epileptiform neuralgia. One of them was sent me by Dr. Pillon, and I shall relate his history presently; the other by a person whom I had cured of simple neuralgia by a very simple treatment also. The paroxysms re- turned nearly every 10 minutes, and lasted 40 or 50 seconds. The pain affected the mental and the infraorbital nerves, and was accompanied by slight convulsive twitches in the whole side of the face. I recommended opium, and prescribed pills containing one grain of opium each, of which 790 ON EPILEPTIFORM NEURALGIA. four were to be taken on the very first day, the dose to be augmented daily, until the pain was notably diminished as to duration and intensity. A dose of scarcely 4 grains a day produced considerable drowsiness, nausea, and loss of appetite, but the paroxysms diminished immediately, and the pain became very bearable. I increased the quantity of opium to 10 and even 15 grains a day. The neuralgia was marvellously modified, but the drug disordered the digestion so much, and caused such disagree- able numbness, that I was not able to increase the doses so as to get com- pletely rid of the neuralgia. With regard to the other case, the following particulars were communi- cated to me by Dr. Pillon, Jr. M. M , aged 54, had served in most of the African campaigns, and had suffered from obstinate intermittent fevers, and pretty serious gastric affections; but, with these exceptions, he had always enjoyed good health. In 1845, he, for the first time, felt in the right cheek pain, which was slight in the beginning, and attended with alternate sensations of heat and formication. This pain varied as to the seat of its maximum intensity, this being sometimes about the region of the canine tooth, and at other times about the chin. It lasted from a few seconds only to two or three minutes. By degrees this pain assumed the character which it presented when I first saw the patient. The paroxysms were more or less frequent, but always set in with the same suddenness, making the patient groan from its severity, and clutch the objects near him. All the muscles of the right half of the face contracted with vio- lence, and pulled the features over to that side. After lasting from 12 to 40 seconds, the pain, which had been awfully intense, ceased as suddenly as it had come on. The patient resumed his interrupted conversation, and was perfectly quiet for a period varying from 15 minutes to several hours. Occasionally the disease assumed a slightly different form. For several hours, several days even, there was no true paroxysm, but slight warnings only, slight shooting pains, which were more frequent in proportion as they were less distinctly characterized. Dr. Pillon, remembering that the patient had suffered from ague, probably caught in Africa, gave him quinine in large doses, but without any benefit. Electricity was employed by Dr. Duchenne (de Boulogne), galvanism by Delacroix; Professor Chomel pre- scribed Dover's powder, and other physicians recommended Meglin's pills (consisting of valerianate of zinc), valerian, belladonna, cyanide of potas- sium. Everything failed. It was under these circumstances that I saw the patient. At that time the paroxysms had become so frequent, and the pain so acute, that his life was thoroughly miserable. His appetite was failing him, and whenever he endeavored to take any food, the movements of mastication brought on the most awful pain. The interval between his fits was only of a few min- utes at the outside. Dr. Pillon counted as many as seventeen in an hour which he spent with him. His life had become so insupportable that he occasionally thought of committing suicide. I decided on trying opium in large doses. In the first half of June, the patient took daily from eight to ten grains of crude opium, twelve grains in the second half of the month, and sixteen grains from the 1st to the 15th of August. During the whole of August this last dose was continued, and the paroxysms became very distant, the pain especially very feeble. Life was bearable again, but violent diarrhoea, obstinate cephalalgia and continued nausea, compelled him to give up the treatment. In spite of this interruption, however, the amelioration due to these very moderate doses of opium continued until the end of October. At that time he had INFANTILE CONVULSIONS. 791 only ten or fifteen paroxysms a day, instead of from fifteen to eighteen an hour; and during the night he had three or four only. These are not excellent results, it is true; but they are favorable upon the whole. Of all the therapeutic agents which I have used-and I have tried a good many with extreme perseverance-opium, then, is the drug which has least disappointed me. But keep this well in mind, gentlemen, that in the treatment of epilepti- form neuralgia, opium should be administered in large doses, which cannot be well determined a priori. They should be gradually increased until the pain is quieted, so long as no unpleasant effects show themselves. It may be laid down as a general rule, that the doses which, in a state of health, give rise to very marked functional disturbances, are on the con- trary well borne in proportion to the intensity of the pain. There are also idiosyncrasies which cannot be known beforehand, and which may com- pletely preclude the administration of opium in sufficient doses. Superficial electric excitation has been, in the hands of Dr. Duchenne (de Boulogne), of great service in the treatment of this obstinate neurosis.* Almost instantaneous relief is sometimes obtained ; but, unfortunately, this important remedial measure fails in the majority of cases to relieve the pain, and to prevent its recurrence. LECTURE XLIII. na-FANTTLE CONVULSIONS. The Organic Alterations are an Effect, and not the Cause, of the Convulsions.- Yet those Secondary Anatomical Lesions should be taken into con- sideration.-Predisposing, Hereditary, and Acquired Causes.-Exciting Causes.-The Convulsive Paroxysm comprises Two Stages, one of Tonic Contraction, and the other of Clonic Movements.-A Third Stage, that of Collapsus, is an Effect of the Convulsion itself.- Convulsions present infinite varieties.- General Convulsions.-Partial Convulsions.-Status Convulsivus.-Inward Convulsions.- Thymic Asthma.-Sequelae.- When Death occurs, it is by Asphyxia, or by Nervous Syncope.-Prognosis.- Treatment. Gentlemen : Scarcely have a few among you had an opportunity of seeing a baby, who was admitted into the St. Bernard Ward the day before yesterday, and who died the same evening. He was nineteen months old, and had only cut six teeth. He had, for the last few days, been seized with convulsions, recurring in paroxysms four or five times in the twenty- four hours. About a year previously, when cutting his first teeth, he had been seized in the same way, and the attack had lasted eight days, as on this occasion, but the symptoms had been different from those witnessed this time, and had constituted what are termed inward convulsions. When his mother brought him to the Hotel-Dieu, the child had there- fore been ill for eight days. Yet, he had not been convulsed on Sunday * " De 1'Electrisation localises et de son application a la Pathologic et a la Therapeutique," 2e ed. Paris, 1861, p. 959. 792 INFANTILE CONVULSIONS. last, and he seemed well, when the convulsions returned on the following day with renewed intensity, so much so, that since Tuesday evening (he was admitted on the following Thursday) they recurred almost uninterrupt- edly. Since that time also, he refused the breast, and remained in a con- dition of true status convulsivus. The convulsions returned every four or five minutes, each paroxysm lasting from thirty-five to eighty seconds. Although they were very rapid, I could still observe that they consisted of two very distinct periods; namely, first, a stage of tonic convulsions, succeeded by clonic ones, which, in the interval of the paroxysms, still persisted in a certain degree, and were exaggerated on the recurrence of the fit. The arms and legs executed extensive movements through the involuntary contraction and alternate relaxation of their muscles. From the commencement of the paroxysm, there was convergent strabismus, and the eyes looked down towards the lower eyelid ; the urine also was passed involuntarily. There was febrile reaction, shown by heat of skin, and acceleration of the pulse (168 in the minute), and the child's mother stated that he had been feverish from the beginning. Lastly, the child coughed, but on care- fully examining his chest, nothing abnormal was detected. The autopsy disclosed no lesion of the nervous centres; yet it seemed to me that the gray matter of the cerebral convolutions was of a slightly deeper tint than it normally is. The lungs were slightly congested and emphysematous, especially the middle lobe of the right lung. You will be frequently called upon in the course, and even at the outset, of your medical career to attend cases of infantile convulsions, and the subject is of such great importance that I mean to devote a few conferences to it. Convulsions, considered generally-and I need not insist on the fact- are met with in a good many morbid conditions of very different nature. In some cases, they seem to arise from manifest anatomical lesions of the nervous system; in others, they seem to be caused by no material change, or, at least, the most rigorous examination after death reveals the existence of no organic alteration to which may be ascribed the morbid phenomena which manifested themselves during life. Hence a great primary distinc- tion between so-called symptomatic and idiopathic convulsions. These latter may be the expression, and sometimes the sole expression, of very different diseases. I have shown you how of themselves they characterized one form of epilepsy, the haut-mal; and you know well the important part which they play in hysteria. They again constitute the predominating symptoms in the various forms of chorea; and the perma- nent involuntary muscular contractions of tetanus, and of the affection described under the name of idiopathic contraction, are only tonic convul- sions. Lastly, under the generic term, idiopathic convulsions, are included the various forms of eclampsia, to which infantile convulsions should be referred. One point is first to be elucidated, before I enter upon their clinical study. I stated that idiopathic convulsions could not be ascribed to the presence of any appreciable anatomical change, but I did not mean thereby that they were independent of a material affection undoubtedly seated in the nervous centres; I merely assert that the most minute dissections have not yet taught us (if they ever can succeed in so doing) the organic patho- logical condition in consequeuce of which convulsions arise. I still less deny that dissection discloses in individuals, who have died in convulsions, more or less extensive lesions of the nervous system, but I will repeat what I have said already when treating of epilepsy, and what INFANTILE CONVULSIONS. 793 I will say of all neuroses, that those lesions are but of secondary importance in the history of the disease. They are, for the most part, the result of disturbances of the nervous system, perhaps of those inappreciable organic modifications to which I have alluded, which have taken place in the ner- vous system, but they are consequences and not a starting-point. Thus, a child is seized with convulsions and dies. On dissection, a more or less marked congestion of the meninges, the brain, and spinal cord, and serous effusion into the ventricles or into the arachnoid sac, sometimes even one or more hemorrhagic centres, are met with. Now are the congestion and the effusion to be regarded as the causes of the convulsions? Surely not. They no more caused them than the cerebral congestions and hemor- rhages which take place in epileptic fits are the cause of the fits; no more than the pulmonary engorgement and serous effusions into the pleural cavities, sequential to paroxysms of asthma, caused the asthma. What we see is the analogue of that transient congestion which brings color into the cheeks of an individual who is under the influence of anger or of a deep mental emotion, and which is, in some cases, carried to such a degree as to involve the brain itself. It may be also compared to the congestions which accompany neuralgic affections, phenomena to which I call your attention every day, and which have been described by Dr. Notta in an excellent Memoir.* The opinion which I maintained, and which is accepted by most practi- tioners, is far from being novel; it was very clearly professed by Morgagni when he wrote in his eighth letter " De causis et sedibus Morborum: " " The cause of convulsions, which consists in an invisible change that has occurred in the brain and nerves, cannot be detected by our senses after death ; its effects alone are seen, and these vary according to the violence and dura- tion of the convulsions." Yet, gentlemen, do not go beyond my meaning, and believe that I attach no importance to these material lesions. Although they occupy but a secondary place as the effects, and not the causes, of con- vulsions, they should not the less be taken into consideration. For, if when slight, they disappear rapidly and spontaneouly as soon as the cause which produced them ceases to act, they are capable, when carried to a very high degree, of bringing on the most serious complications. When they recur frequently, they may cause anatomical changes, and subsequently incurable functional disorders ; if there be no immediate danger of life, the patient be- comes, at least, subject to incurable infirmities, as we have seen ; for instance, epileptics remain paralyzed after convulsive seizures ; a fortiori, should we take into account the extravasations of blood which result from an attack of eclampsia. I shall revert to those points. We cannot find out, then, what the ancients called the proximate cause of convulsions, but we know better their predisposing and exciting causes. In our conferences on epilepsy, I tried to prove to you by facts the influence of hereditary predisposition on convulsive disorders. This ner- vous susceptibility manifests itself in different generations either in the same or in a different way. It pretty commonly happens that parents, mothers especially, who in their infancy were subject to fits, give birth to individuals who are in their turn affected in the same way. One of the most extraordinary instances of the kind, which I know of, is that related by my old pupil and friend, Dr. Duclos (of Tours) in his remarkable thesis.f The case is that of a woman, thirty-four years of age, * Memoire sur les lesions fonctionnelles sous la dependance des Nevralgies. Archives Gen. de Medecine, 5e serie, tome iv, juillet, septembre, novembre, 1854. t Etudes eliniques pour servir a 1'histoire des convulsions de 1'enfance. Paris, 1847, p. 75. 794 INFANTILE CONVULSIONS. the sister of ten children, six of whom died of convulsions, and who had herself had frequent attacks of eclampsia up to the age of seven. These had left behind slight deviation of the mouth and ptosis of the left upper eyelid. This woman had ten children, who all had convulsions; six had died, five in the first two years, and one when three years old. Her young- est, whom she brought to me at the Necker Hospital, was a little girl six months old. Three months previously she had had a first attack, which had lasted about ten minutes, and which her mother ascribed to her having given the breast to the child immediately after a fit of passion, as the convulsions occurred on the ensuing day. Death took place, three months afterwards, from cerebro-meningitis. Accoucheurs have often remarked that infants, whose mothers had eclamp- tic seizures shortly before delivery, were liable to convulsions within a short time after birth. In some cases, death results from the violence of the fit; in others, the child gets well although the paroxysms have been very fre- quent and have recurred at very short intervals. The same authorities state also that they have seen infants at birth with contractions of the limbs or muscles of the neck, which were the result, according to them, of convulsions or of some analogous affection at least from which they had suffered in utero, the mothers having had convulsions during pregnancy. Independently of this predisposition transmitted from parent to offspring, there are a series of causes which predispose to convulsions in a singular manner, namely, all those which tend to weaken the system. Hence con- vulsions are most frequent in children who are insufficiently fed, who have lost a relatively large quantity of blood, whether from spontaneous hemor- rhage, or from venesection, or the application of leeches. Profuse diar- rhoea, persisting for a long time, acts in the same way. This need not sur- prise, if this great physiological law be kept in mind, namely, that in pro- portion as the nutritive and vegetative functions are feeble and languish- ing, nervous phenomena are mobile, exalted, and irregular-a law which has been admirably enunciated in this simple observation of Hippocrates, sanguis moderator nervorum; if it be especially remembered that the depen- dence of the nervous system on the blood and the nutritive functions is most strikingly marked in children. I shall not enumerate to you the long list, given by authors, of the excit- ing causes of infantile convulsions. I shall only remind you that a high temperature, sudden exposure to cold, mental emotions, and local irritation, can bring them on. A few years ago, I was asked to see, with my friend and colleague Dr. Blache, the child of a foreign minister accredited to the French government. The child had for some hours been seized with paroxysms of convulsions, for which he had been put in a bath. The convulsions did not cease, when Dr. Blache, on removing the child's cap, saw a piece of thread across his head, and on trying to take it away, pulled out a long needle which had entered the brain. The convulsions ceased immediately, and hydrocepha- lus set in shortly afterwards and carried off the patient. A son of my excellent colleague Professor Soubeiran, having died of convulsions, for which no cause could be assigned, a post-mortem examina- tion was made, when a needle was found transfixing the liver, and to this cause the convulsions were referred. Underwood relates a case like my first in his Treatise on Diseases of Children. A child, after incessant crying, had been seized with convulsions, which could not be clearly accounted for by the medical attendant until after INFANTILE CONVULSIONS. 795 death. On removing the child's cap, a small pin was found sticking into the anterior fontanelle. Bear these facts in mind, because you may happen to see convulsions cease when you find, on undressing the little patient, that a badly-placed pin, or even a painful constriction of the dress, was the starting-point of the convulsions. Remember, also, that fits are often brought on by the application of blisters, of sinapisms to the limbs of children, with the intention of com- bating nervous disorders of no gravity. How often have I seen convulsions which terminated in death, supervene in children that had been covered over with blisters ; and how often have I seen medical men use fresh blisters against the evil they had themselves caused, forgetting the nervous symp- toms which so frequently accompany a burn of the first degree. The convulsive seizures that are so common in some children, not only during the first dentition, but also, although much more rarely, during the second, are to be ascribed in a great part to the irritation caused by the difficult evolution of the teeth. In an etiological point of view, cbnvulsions that are connected with well- defined physiological conditions, are undoubtedly the most interesting to study. Those which are due to an appreciable organic alteration of the nervous centres, such as the convulsions of cerebro-meningitis, need not occupy our attention, and the history of such symptomatic convulsions forms part of that of the disease of which they are one of the manifestations. But convulsions which, from their occurring at the onset, during the course or towards the close of various diseases, are termed secondary, and said to result from sympathy, are referable to eclampsia properly so called, of which those diseases should be regarded as exciting causes. Such are the convul- sions which occur at the outset of eruptive fevers, of measles, and of small- pox, more frequently than of scarlatina ; at the commencement of pulmo- nary or intestinal catarrhal affections; in a word, of most of the inflammations or fevers which attack children. Apart from these catarrhal or purely inflammatory affections, and from chronic diarrhoea, disorders of the alimentary canal have the greatest influ- ence on the production of convulsions. Indigestion is one of their most frequent causes, whether due to excess in the quantity of food, as when the child is given too much milk which is good in all respects ; or whether it is the consequence of the use of coarse food, which is not adapted to the age, the digestive capabilities, and the individual dispositions of the child, as when infants at the breast are fed, at too early an age, on thick panadas, on haricots, on lentils, or on potatoes, &c., as you will too often have occasion to see. I wish to dwell very strongly on a point to which I have already called your attention, and to which I cannot too often revert; namely, that, con- trary to the generally accepted notion, children at the breast, who are subject to diarrhoea, are much more frequently liable to convulsions than those whose motions are habitually regular, not because diarrhoea predis- poses to eclampsia more particularly, but because persons whose bowels are delicate and often disordered, are more than others liable to indigestion, which is a powerful cause of convulsions. Hence I have for many years laid down a rule for myself, to stop the diarrhoea of children even when they are teething. Cases have been recorded of children who had been seized with convulsions, after taking the breast soon after the mother had felt a violent emotion. I saw at the Necker Hospital, to which I was physician for a long time, eclampsia come on in a child whose nurse had had a violent fit of passion a moment before giving him the breast. Pro- 796 INFANTILE CONVULSIONS. fessor Andral related in his lectures still more curious instances, showing that there are singular idiosyncrasies, under the influence of which the milk of a nurse is well digested by some children and not by others. " A woman nursed her own child without any ill effect, but another child to whom she gave the breast was seized with convulsions and a third like- wise." In all such cases, the seizure comes on without any other symptom of indigestion being present; it seems as if the nature of the milk was altered under the influence of some cause or other, and it became a poison acting on the nervous system. I have already called your attention to the important fact, pointed out for some years past, of eclampsia coming on in children as well as adults, as a consequence of albuminuria, whether it occurs in the course of an acute affection, as it often does at the close of scarlatina, or whether it be a symptom of Bright's disease. In such cases, the patient has generally had more or less considerable anasarca; but you must not think, as some seem to admit, that anasarca is the most favorable condition for the development of convulsions; because, on the one hand, children who become anasarcous without passing albu- minous urine after an attack of dysentery, of obstinate diarrhoea, of measles even, are rarely seized with eclampsia, whilst in albuminuria without ana- sarca, convulsions are of frequent occurrence, and so much so, that some authors have not hesitated to affirm that, in nearly every case, infantile convulsions were a symptom of albuminuria, an opinion which to me seems exaggerated. Those authors have even tried to diagnose eclampsia from epilepsy by the presence of albumen in the urine in convulsions. I have often reminded you of Professor Claude Bernard's curious experiments on the influence of injuries to the fourth ventricle on the urine. If, in an animal, this ventricle be injured in a certain spot, the urine is found to con- tain sugar within a short time, and to be secreted more abundantly. If some other spot be wounded, mere polyuria follows, and no sugar is found in the urine. An injury to a third spot soon renders the urine albuminous.* Can it be supposed, then, that the same venous modification which, in a child or in a woman, produces albuminuria, causes a liability to eclampsia? The presence of worms in the alimentary canal has been mentioned by all authors as one of the most common exciting causes of infantile convul- sions, and I have already told you of a case of epilepsy which was cured by the expulsion of a taenia. Such cases are instances of reflex convulsions. Without attempting to review all the causes of infantile convulsions, I will call your attention to this peculiarity; namely, that circumstances apparently the most insignificant may bring them on in individuals predis- posed to them; that there are children who are convulsed with as much facility as others pass into a dreamy or delirious state; and that this pre- disposition is chiefly hereditary. As I have already told you when speak- ing of epilepsy, this nervous susceptibility or excitability may in some cases be foreseen. Care, however, should be taken not to mistake for convulsions the rapid and involuntary movements which occur, even in the waking state, in individuals whose nervous system is very excitable, when surprised by an unexpected noise, or when under the influence of sudden mental emotion. Such movements are convulsive in appearance only, but fail to present the essential characters of convulsions properly so called. Let us, then, see what these characters are. Viewed in its simplest ele- ment, a convulsive seizure consists of two successive and very distinct stages. * Lemons de Physiologie experimentale appliquee a la Medecine faites an College de France. INFANTILE CONVULSIONS. 797 The first stage is one of contraction without shocks, consisting in a gradual but rapid shortening of the muscular fibres, shown by the hardness and stiff- ness of the affected muscle, which cannot be overcome in some cases. This period of tonicity is soon followed by a clonic stage, characterized by the occurrence of alternating movements of contraction and relaxation inde- pendent of the will, which is as powerless to suspend or moderate them as it was to excite them. The tonic always precedes the clonic stage, but the duration and violence of the latter are by no means proportionate to the duration and violence of the former. Thus very violent clonic movements often succeed a slight tonic contraction, and reciprocally an excessively powerful tonic contraction may be succeeded by very moderate clonic movements. Thus the length of the first stage is sometimes so short, and the second stage comes on so quickly, lasting for a more or less prolonged period, that an observer who is not on his guard, or not very attentive, might think that the convulsions were clonic from the outset. In other cases, which are not so frequent it is true, there are no clonic convulsions, and there is only during the whole time a muscular contraction more or less energetic and persisting. This is what occurs in idiopathic contractions, of which I shall speak on some other occasion. In eclampsia, more especially in the eclampsia of children, of which alone I mean to treat to-day, clonic convulsions are absent when death occurs during the fit, and as a consequence of the length of the tonic contrac- tion, from asphyxia or syncope, by a mechanism which we shall investigate by and by. From what I have said, this remarkable fact follows, that rigidity seems to be an essential, obligatory element of all convulsion. It is never absent, and can even be alone present, whether it constitutes the convulsion by itself, as in idiopathic contractions, or whether the convulsion is incomplete, as in eclampsia, when the clonic stage is absent, whereas clonic movements never perhaps come on from the first. There is a third stage which should not be omitted, although it does not form part of the convulsive seizure, namely, that of collapse, stupor, or coma. Whether it be the consequence of cerebral surprise, produced by congestion or exhaustion of the nervous excitability, this collapse is an effect, and not the cause, of the convulsions. If in most cases there sets in after an attack of eclampsia, more or less profound, or more or less tran- sient stupor, in some instances of very infrequent occurrence, it is true, there is no transition between the attack and the return to a normal state. After this analysis of the various phenomena which constitute a convul- sive fit, I now pass on to a more general study of infantile convulsions, and will attempt to describe them as completely as possible. The subject is one of extreme difficulty, for eclampsia assumes the most varied forms. More commonly it comes on like an epileptic fit. Nothing foretells the in- vasion of the attack; and, for my part, I have never observed the premoni- tory signs spoken of by Brachet, and repeated after him by others. The state of impatience, of uneasiness, of agitation, and malaise that is spoken of, the light sleep or the wakefulness, sometimes, on the contrary, replaced by languor, hebetude, and somnolence, are the prodromata of the disease, of which the convulsions are a primary manifestation, and cannot be referred to the convulsions themselves. The convulsions set in suddenly. The child utters a cry, loses conscious- ness, becomes rigid, and struggles, with a fixed chest and suspended res- piration ; the face, which is pale at first, becomes red and livid; the eyes sometimes fill with tears, which run over the cheeks; the veins of the neck project like knotted cords. The clonic stage then begins, characterized by disorderly and involuntary contractions of a great many muscles; the 798 INFANTILE CONVULSIONS. limbs are alternately flexed and extended ; the fingers and toes are succes- sively bent and stretched out, separated from or approximated to one an- other, but most frequently they are in a state of forcible flexion ; the thumb is adducted and hidden by the fingers. The head is drawn backwards or is bent forwards; sometimes it is pulled laterally by irregular and jerking rotatory movements; the muscles of the face share in the general convul- sions; the eyes are the seat of jerking movements, and roll in their sockets ; they are generally drawn up under the upper eyelid ; more rarely they are pulled downwards, and there is strabismus convergens. The labial com- missures are dragged upwards and outwards, and hence the distorted face is sometimes frightful to behold; then, on each convulsive shock, the air passes through the kind of funnel formed by the corners of the half-opened buccal orifice, and makes a suction noise, accompanied by a flow of frothy and sometimes bloody saliva. In this, as in an epileptic fit, the tongue is protruded, and may be bitten and lacerated by the teeth. As the muscles of the trunk are likewise affected during the tonic stage, the inspiratory muscles are fixed, and the larynx itself, which is spasmodically contracted, no longer admits of the free passage of air. The abdominal muscles being thrown into convulsion, cause the involuntary expulsion of the urine and feeces. The clonic convulsions, at first rapid and limited, become slower and more extensive, and at last a deep inspiration, followed by complete relaxation, announces the end of the fit. The child then falls into a state of somnolency and stupor. These various phenomena take place in much less time than I have been in describing them, and the fit, which is always too long for the frightened mother, lasts one or two minutes. When it is completely over, and when, after the stupor has disappeared, order is re-established, it is impossible to see any traces of what has passed, beyond that the child shows signs of fatigue by yawning and by a tendency to sleep. The paroxysm may consist of a single fit, but this is rare. Generally, after a more or less prolonged pause, a second fit comes on, having the same characters as the first, lasts the same length of time, and is, like it, succeeded by coma, after which the child recovers his normal condition. Like the first, it conies on without any appreciable cause, but it may be brought on by emotion, by annoyance, by pain, or by movement, and may recur every hour, every half hour, and even at nearer intervals. An attack of eclampsia thus. composed of several fits, may last from half a day to one, two, or three days; and there are instances in which it has been prolonged beyond that time, the child being liable to convulsions, which, recurring at more or less short intervals in the course of the twenty- four hours, are continued over five, six, seven, and fifteen days, as in cases reported by Dr. Duclos,* and even over eighteen days, as in the case of a child, five months old, whom I saw at the Necker Hospital. During an attack of hooping-cough, this child had every day one or two paroxysms, consisting of a series of subintrant fits; that is to say, of fits following one another so quickly that one fit was not yet over before the next one began ; the paroxysm lasted in this way, without the least inter- ruption, for two, three, and even four hours, f This, gentlemen, confirms what I told you just now as to the variety of forms assumed by infantile convulsions. Generally intermittent, separated by intervals of rest, during which order seems to be re-established, they are found, at other times, as in the above case, to succeed one another without intermission. A fit which has lasted * Loc. cit., p, 23. + Id., p. 23. INFANTILE CONVULSIONS. 799 one or two minutes, is scarcely over when it is followed by another, which is, in its turn, succeeded by from one to twenty other fits ; so that the little patient merely passes from the contortions of convulsion into a still more awful torpor ; and from want of attention, many medical men consider this state as one of continued convulsion. A little care is alone needed in order to recognize a series of paroxysms, the violence of which is generally, in such cases, less great than that of intermittent convulsions. This condition resembles exactly what in epi- lepsy I termed the status epilepticus, a condition of much less frequent oc- currence, however, in epilepsy than in eclampsia. These apparently continuous convulsions may last a considerable length of time, for eight or ten hours, then, after a more or less prolonged inter- val, may again assume a continuous form, and recur from one to two and even to fifteen or seventeen days in succession. This form of eclampsia, therefore, differs from the one in which the attacks are markedly intermittent, only as regards the mode of recurrence of the fits. There is, however, a continuous form, which is pretty often met with after a violent epileptiform seizure. Just as the jerks are expected to cease, they return every second or at slightly longer intervals, and this goes on for a quarter of an hour, for an hour, or even for whole days. In such cases, there is, in reality, but a single attack ; for although from time to time the convulsions seem to diminish in intensity to begin again with renewed violence, there is never a complete cessation of the convulsions, nor the profound stupor and the general muscular relaxation which follows on an ordinary paroxysm. In this continuous form of eclampsia there is a capital symptom to which I wish to direct your attention at once. Whereas in the first two forms, there was loss of consciousness, in this form, on the contrary, although the child is convulsed, he seems as if he had not entirely lost consciousness, and was not a complete stranger to all that was passing around him. He expresses his wants or pain by cries; he occasionally withdraws with a certain amount of vivacity his hand when it is pinched, or his foot when it is tickled, although the very limb is convulsed which still responds to the commands of the will. In truth such convulsions, which affect the whole body, are not so general as they seem to be, since there are some muscles which still obey the will, and they must therefore be regarded as partial, strictly speaking. Let us now pass on to more localized convulsions. Partial convulsions present the most marked differences, and their infinite diversity of form is in direct relation to their seat. It sometimes happens after an epileptic fit that one-half of the body is for several hours the seat of spasmodic clonic movements, which recur at intervals or from one to several seconds. The child is yet perfectly conscious, and the movements of the opposite half of the body are executed with an ease and a co-ordination which contrast sin- gularly with the agitation of the affected side. I remember seeing a little boy of eleven months old with the tubercular diathesis, who, after a violent attack of eclampsia, recovered his senses, but whose right arm and the right half of whose face were convulsively and violently agitated for several hours. He knew his mother and his nurse; could drink, although with some difficulty; looked with attention and intelligence at all the objects around him, turned his head quickly round to look at the persons who entered the room, and sometimes even, worried by the jerks of his right arm, tried, by holding it with his left hand, to stop the violence of the convulsive movements. In other cases, instead of affecting in an equal degree all the muscles on 800 INFANTILE CONVULSIONS. one side of the body, convulsions affect unequally one muscle or another, and often muscles which are not supplied by the same nerve. Thus only one muscle of the arm, the biceps, for instance, may be convulsed, while the others are perfectly quiet and relaxed, and one or more fingers are alone moved. Occasionally, although more exceptionally, the lower limbs are the seat of these partial convulsions. They are frequently preceded and accompanied by the general disorders which characterize an epileptic fit, such as a scream, loss of consciousness, and pallor of the face; often, also, the attack is followed by a period of stupor and carus. These phenomena are never more marked than in the cases when the convulsions are limited to the trunk, cases, which although not rare, are yet much less frequent than those in which the limbs are exclusively convulsed. Partial convulsions of the trunk assume, besides, two very distinct forms. They are sometimes incomplete, and consist of an exclusively tonic con- traction of the muscles of the vertebral groove, which resembles a true tetanic spasm. The body stiffens; the head is drawn backwards and immovably fixed ; and then, without there having been any flexion, all contraction ceases, and the normal condition is restored. Sometimes this tonic stage is so transitory that it seems to be absent, and clonic contrac- tions are alone seen, which make the head rotate or bend forwards or back- wards, the convulsions seeming to be exclusively limited to the muscles of the neck. I will here jrepeat an observation which I have made already, namely, that you should not confound with convulsions certain move- ments which somewhat resemble them, and which recur in a-great many children during a febrile affection. Such movements show the excitability of the little patient, and although they are due to an exaltation of the ner- vous system, are in reality not convulsive. Of all partial convulsions the most frequent are unquestionably those of the face. They sometimes involve all the muscles of one half of the face, when the eyelids, the globe of the eye, the ala nasi, the cheek, are thrown into convulsive contractions, the mouth is distorted, the lower jaw is depressed and pulled to the affected side, and the teeth are set, or there is a kind of chewing movement continually going on. In some cases the con- vulsions are still more limited in their area, involving either the orbicularis palpebrarum, and causing rapid involuntary winking, which lasts more or less time, or a few muscular bundles of the cheeks and lips, the commissure of the latter being then violently dragged upwards and outwards, or the muscles of the ala nasi, causing alternate dilatation and closure of the nos- tril. The muscles of the tongue are sometimes affected, and articulation being then impossible, there results a kind of stammering, which is gener- ally transient, but sometimes persistent. Convulsions of the muscles of the eye are the most frequent of the partial convulsions of the face, and I will go so far as to add that they are per- haps very often overlooked. They generally announce the invasion of an attack of eclampsia, but sometimes also they are the only symptom of the complaint. They are, in some cases, exclusively tonic; the globe of the eye is drawn up and hidden under the upper lid, or there is double and convergent strabismus; in exceptional cases the strabismus is divergent. In other instances one eye is alone affected, and the other is perfectly mo- tionless ; the strabismus is then almost always convergent. It may also happen that the strabismus is convergent on one side and divergent on the other. Usually the convulsions of the muscles of the eye are complete; that is to say, permanent contraction is succeeded by clonic movements, and the globes of the eye oscillate continuously, being drawn up under the INFANTILE CONVULSIONS. 801 upper lid, and then pulled down under the lower one, and looking inwards towards the nose much more frequently than outwards. With respect to one point you must be on your guard. You will proba- bly be more than once called upon to see children said to have been seized with convulsions, because their eyes shall have been seen to be drawn up under the upper eyelids whilst they are asleep, and this essentially physio- logical condition has been mistaken for the consequence of convulsions. The eyes are sometimes drawn up to such a degree that on separating the lids, the iris, and the pupil particularly, cannot be seen at all. The pupil is besides completely contracted, whereas during convulsions it is, on the contrary, more or less dilated. This physiological condition gives rise to frequent mistakes, especially when children have recently had true convul- sive seizures. It is easy, gentlemen, to recognize eclampsia under the different forms which I have just reviewed, however elementary or partial it may be. These forms are perfectly distinct and special, and all medical men agree, if not on the nature of the disease, at least on the name which should be applied to it. The case is always one of convulsions. But opinions have differed, and still vary very much, with regard to the forms to which I now' pass on, namely, inward convulsions, to which, when slight, some authors have applied the term spasms; and which, according to the muscles that are affected, give rise to phenomena which are differently and sometimes singularly interpreted. By inward convulsions are commonly meant partial convulsions, more particularly of the pharynx, of the larynx, and of the whole muscular respiratory apparatus. The term has certainly not a very clear and pre- cise meaning, but it is good enough, provided its meaning be well under- stood. The most common form of inward convulsions consists in the drawing up and the mobility of the globe of the eye, of which I spoke just now; in a nearly complete loss of consciousness, or at the very least in pretty profound stupor; in extreme difficulty or inability to swallow ; in uneven breathings sometimes scarcely perceptible, sometimes deep, broad, and blowing, show- ing that the diaphragm and the respiratory muscles of the abdomen and chest are more particularly involved; sometimes there is heard for one or several minutes a peculiar laryngeal whistling, which indicates an obstacle to the entry and exit of the air, a circumstance to which I shall revert presently. Inward convulsions may coexist with general or partial convulsions of the limbs and face (for I have told you that these were usually accompanied by convulsions of the globes of the eyes), or they may be alone present. In either case, again, they may be complete, that is, tonic and clonic, or incom- plete, and consequently consisting in tonic contraction alone. If, in the former case, the patient be exposed, the convulsions of the diaphragm and the respiratory muscles may be seen to cause very rapid and frequent, though not extensive, movements of the base of the chest; in the latter case,, the base of the chest is violently drawn in and remains immovable. Clonic convulsions, owing to the frequency of their recurrence and the shallowness of their movements, necessarily produce profound perturbation of the re- spiratory function, which becomes embarrassed, and therefore of haematosis. Again, the convulsive jerks explain the slight and peculiar fits of coughing which frequently accompany inward convulsions. Tonic convulsions suddenly arrest and completely suspend the respiratory functions. Hence you can easily understand that they cannot last for a long time continuously, without causing death. So that, whereas convul- VOL. I.-51 802 INFANTILE CONVULSIONS. sions of the limbs and face may extend, without any inconvenience, over a minute and a half and two minutes; tonic convulsions of the diaphragm and of the inspiratory muscles must be transitory only, and cannot last over a minute without immediate danger. Inward convulsions chiefly consist, then, in convulsions of the diaphragm and of the respiratory muscles of the abdomen and chest; but it happens also that the intrinsic muscles of the larynx are convulsed simultaneously, and this laryngeal convulsion causes again disorders of respiration, which may, in some cases, excite serious alarm. A rickety child, subject to epi- leptiform convulsions, which, for the last few months, had recurred several times a day under the influence of the least fit of anger, was one day brought to me at the Necker Hospital. He had besides, from time to time, attacks which his mother could not describe clearly, but which, according to her statement, were still more grave than the great seizures. Several of these attacks occurred in my presence. The child suddenly threw himself back- wards, his throat was tense, his mouth half-opened, his eyes fixed, his arms and legs moved by convulsive jerks. Quick inspiratory movements created inside the chest a vacuum, which was immediately removed by the falling in of the ribs; air seemed not to enter the larynx, or, if a little went in, it caused a sharp whistling noise, somewhat similar to that which is sometimes heard during the most violent paroxysms of croupal dyspnoea. During the attack, the face, neck, and chest, and the mucous membrane of the mouth, became more and more livid in hue, until, as the spasm ceased, one or more deep inspirations put an end to this terrible scene. Profound depression, like what follows an attack of eclampsia, then ensued. It is these convul- sions which affect the respiratory apparatus, and the larynx more particu- larly, that constitute the disease described by Kopp under the name of thymic asthma, the laryngismus stridulus of Hood and of Ley, and on which my colleague, Dr. Herard, has written a good monograph.* Allow me, gentlemen, to dwell a moment on this question, which has given rise to much discussion. You are aware that this complaint has been ascribed to an abnormal development of the thymus gland, but it has been conclusively shown that it is perfectly independent of it. First of all, is it necessary to state that the thymus gland, as well as the suprarenal capsules, organs of transition which are destined to atrophy after birth, are, less than other organs in the body, placed in conditions that give rise to hypertrophy? For more than twenty years I was attached to a hospital where a large number of very young children was admitted, and I never once saw swelling of the thymus gland that was capable of giving rise to the slightest accident. Besides, is it conceivable that the thymus may grow to such a size as to obliterate the trachea to a great degree without the child's friends and the medical attendant being warned by the presence of habitual dyspnoea? And if there has never been any dyspnoea, can one understand by what process an organ, which contains so few bloodvessels, may in a few minutes become a cause of death, or, at least, of awfully serious accidents? Now, if the hypothesis be suggested, that the gland, on undergoing hypertrophy or alteration, has involved the recurrent laryngeal nerve, as in cases of tubercular infiltration of the lymphatic glands of the neck and the roots of the bronchi, how can one believe that there has been no modification of the voice or of respiration, and that the disease reveals itself only by a sudden attack of dyspnoea ? • Pathological anatomy has by this time thrown sufficient light on this contested point, and has shown that if the thymus is sometimes abnormally * Dii spasme de la glotte. [Theses de Paris, 1847.] INFANTILE CONVULSIONS. 803 developed, its hypertrophy is not necessarily attended during the child's life with symptoms of the so-called thymic asthma; whereas in fatal cases of inward convulsions, like those described under the name of thymic asthma, the gland has undergone no alteration. The study of the symptoms could, after all, but lead to the conclusion that convulsions were alone in question, for, on investigating the series of the forms of eclampsia, one can easily rec- ognize convulsions affecting the respiratory apparatus, the diaphragm, and more particularly the larynx. Who does not see that there need only be a want of harmony between the spasmodic movements of the diaphragm and those of the muscles which move the arytenoid cartilages, in order to give rise to the laryngeal whis- tling and the dyspnoea ? In a regular act of inspiration, the upper por- tion of the larynx opens, while the diaphragm is depressed and makes a vacuum inside the chest. Now, if the diaphragm be depressed too rapidly, and there be at the same time laryngeal spasm, as happens in hooping- cough, inspiration becomes almost impossible, and is accompanied by a very loud whistling. In the present instance we need not have recourse to a want of harmony between the movements of the diaphragm and those of the laryngeal mus- cles ; we need only suppose that the will or instinct no longer presides for a moment over the movements of the arytenoid cartilages; the muscles which move these cartilages, no longer responding to a nervous impulse, are for the time in the same condition as those of animals whose recurrent laryngeal nerve has been cut. What occurs deep in the larynx may sometimes take place under the observer's eye. In order to test the truth of the theory which I had framed to myself regarding the so-called thymic asthma, I have on occasions remained a long time by the side of a child suffering from convulsions of the diaphragm, without participation of the larynx, and have brought on at will the phenomena of thymic asthma, by closing for a moment the child's mouth and nose. When the mouth was closed, and the nostrils pressed slightly, so as to occlude them for a second only and then to leave them half-opened, at the moment when a greater convulsion of the diaphragm carried the air more rapidly through the nasal fossae, the alae nasi, yielding to the pressure of the air, were seen to press against the septum, and so intercept the passage of air, so that immediate suffocation resulted. The reason of this was, that during the convulsions, the alse nasi did not open during the forcible in- spiration, as they do in a physiological and even a pathological condition. I need not remind you of the distinction between thymic asthma, and the acute asthma of Millar: the latter is stridulous laryngitis, in which the spasm of the larynx which characterizes it is due to an inflammation of the respiratory tract. Thymic asthma may be preceded or accompanied by other symptoms of eclampsia, but it may also be the only manifestation of the complaint. It may set in suddenly in the midst of apparently splendid health, without any appreciable cause, but it more confmonly comes on under the influence of some mental emotion or of a fright. I was once consulted for a little boy, who from the beginning to the end of his first dentition was subject to such seizuress. He was.of a very excitable temperament, and the least an- noyance brought on an attack : although he is still very excitable, he never, however, has any such attacks now. Remember what I told you already in our conferences on epilepsy, that these laryngeal spasms, and eclampsia, in general, are, in some cases, the prelude of epilepsy, which, as the individual grows older, manifests itself 804 INFANTILE CONVULSIONS. more clearly. On this account, therefore, you should be extremely re- served in your prognosis of thymic asthma; and for a greater reason still, namely, that the patient may be carried off in a fit, when it lasts beyond a certain time, although when the attacks are very short, they are not grave in themselves. Indeed, it is very remarkable that eclampsia in children generally leave after it no traces of its passage, even though the seizures have been frequent and violent, and have recurred during five, eight, ten days, and even more. The little girl, whom I spoke of in the course of this lecture, got perfectly well, and her health did not seem to have suffered in the least from the convulsions which had recurred during eighteen days. In some cases, however, convulsions are followed by sequelae, which may be temporary, or may be persistent and irremediable. Thus, muscles which have been particularly and most violently convulsed, are sometimes, after an attack of eclampsia, the seat of pretty acute pain, resulting either from laceration of their fibres, or effusion of blood, when the pain is not simply a consequence of the fatigue felt after exaggerated muscular efforts. In other cases, more or less incurable deformities result from attacks of eclampsia. You are aware that among the theories propounded to explain certain distortions of the neck in newborn infants, certain congenital de- formities of the limbs, and talipes in particular, there is one which admits the influence of convulsions of the foetus in utero. These infirmities may be brought on after birth ; and you know that eclampsia is regarded as one of the most frequent causes of squinting and. of stammering. It should he added, it is true, that these acquired infirmities are most frequently the result of convulsions that are symptomatic of an appreciable lesion of the nervous centres, and that they are then less due to the convulsions themselves than to the persistent organic cause which brought on the fit. Sometimes, again, eclampsia is accompanied or followed by paralysis. In some instances, the parts which were convulsed are, after the attack, markedly weak, and this weakness may be carried to absolute loss of motor power; in other instances, the limbs on the opposite side are paralyzed; lastly, the upper limb may be convulsed, while the lower limb on the cor- responding side is paralyzed. The paralysis is generally transitory, like the convulsions which accompany it; but it may last more or less per- manently after the attack. It may be partial also, and, like the convul- sions, may affect only one or several muscles. This is especially the case with the face; and these accidents, which occur either on the same side with the convulsions, or on the opposite side, seem to give rise to a certain number of cases of facial paralysis, the origin of which is vainly sought for elsewhere. This secondary paralysis partly explains some of the deformities to which I have alluded, and which are in fact owing to the permanent contraction of one or several muscles. Now, if contraction may follow on convulsions, it is well known also that muscles, which have been long paralyzed, are, after more or less time, subject to it. Lastly, idiotcy very often supervenes on infantile convulsions; and it rarely happens that in such cases one half of the body is not weaker than the other, the paralyzed side being less de- veloped than the sound one. It is then probable that the convulsions have been accompanied or followed by deep lesions of the nervous centres. Although these sequelae of convulsions are not very rare, on the other hand, they are not frequent in proportion to the extreme frequency of eclampsia; and I may here repeat what I said just now, namely, that, generally speaking, this complaint is usually of no gravity. The fatal INFANTILE CONVULSIONS. 805 cases, however, to which I have more than once alluded, and in which death was an immediate consequence of the attacks, are still too frequently met with for not warning you of the possibility of this awful termination. It is to be dreaded, not only after numerous attacks, recurring in rapid succession, but even in a first attack. Death then takes place, either by asphyxia (and this is the most common mode), or by syncope; or, lastly, by nervous exhaus- tion. Asphyxia may be the consequence of inward convulsions, or of the great seizures. In the former case, it is brought on in two very different ways. It may be immediate, as when the child dies choked, as if strangled, or as if his chest were violently and suddenly compressed by an iron hoop. This occurs in thymic asthma, in convulsions of the diaphragm, when the tonic contractions persist for more than a minute and a half, or two minutes, at the most, and thus completely arrest the respiratory movements, and sus- pend the function of an apparatus, the exercise of which is immediately necessary for the maintenance of life. * A young child, of whom I have often spoken in this lecture, died in that manner, and I shall now relate in detail the history of his case: He was eleven months old when he was admitted into the Necker Hos- pital, to which I was then attached, and placed in cot No. 11, St. Julia Ward, under my care. He was suffering from chronic diarrhoea, which improved under the influence of small doses of calomel combined with opium. In other respects the child, who was nursed by his own mother, exhibited no extraordinary symptom, when he was suddenly seized one night with eclampsia, without any premonitory symptoms. The right arm alone was convulsed, and after all slightly so. Inspiration, however, was attended with a kind of sob, somewhat similar to that of hooping-cough. These accidents, which recurred at pretty short intervals, still persisted as I was going round the ward, and returned several times in my presence, each attack lasting less than a minute, without producing any notable dyspnoea. After I had seen the other patients, I returned to the child, and had him completely stripped, and held by a nurse, so as to examine him carefully. He was then suddenly seized with tonic convulsions of the right arm, whilst his respiration quickened, and was attended with the kind of noise I mentioned just now. Within eight or ten seconds his arms and legs, and his whole trunk, became the seats of tetanic rigidity, analogous to that which obtains in the first stage of an epileptic fit. His chest-walls were fixed and motionless, his diaphragm did not move, and breathing was completely arrested. I was looking on with the greatest anxiety, impa- tiently waiting for clonic movements, or the least muscular twitching, when, after less than a minute of complete immobility, I saw the skin, which until then had retained its normal hue, turn livid, the face swell, and the enlarged tongue protrude out of the mouth, driving out some froth, and the urine flow copiously. I endeavored to excite respiratory mdvements by squeezing and rubbing the chest, but my efforts failed, and the child died. On making a post-mortem examination, I found slight injection of the pia-mater, as well as of the gray substance, and perhaps some slight soften- ing of the brain, a condition which might be explained by the high tem- perature of the season. The most minute examination disclosed no lesion. The thymus gland was slightly larger than it usually is, but was neither indurated nor injected, and did not in the least compress the trachea. The lungs were merely engorged and full of black blood, and the bronchi con- tained some froth. One of the bronchial glands was slightly swollen and softened. 806 INFANTILE CONVULSIONS. The second mode in which inward convulsions bring on asphyxia is per- fectly different. The convulsions are complete, but the alternate contrac- tion and relaxation of the respiratory muscles succeed one another at such short intervals, that they do not allow' the chest, and consequently the lungs, to expand sufficiently; and from spasm of the upper opening of the larynx recurring almost uninterruptedly, the air can no longer pass freely into the larynx, trachea, and bronchi. The blood is no longer regularly aerated ; because, on the one hand, the respiratory apparatus no longer receives a sufficient quantity of pure air, and, on the other hand, it cannot get rid of the air which has lost its oxygen, and has therefore become use- less for respiration. This function is in consequence insufficiently and incompletely performed, and asphyxia supervenes, as in cases of organic diseases of the larynx, in cedematous laryngitis, for example. Death by the lungs may also take place in the great seizures, although less immediately than in the two preceding cases. As Dr. Duclos justly remarks, the mode in which the fatal termination occurs is somewhat an- alogous* to what happens so frequently after tracheotomy when performed in the last stage of croup. It would seem as if all danger had been removed after an opening has been made in the trachea through which air may freely pass on to the lungs. Yet asphyxia continues, or at least we can no longer prevent the effects resulting from too prolonged disorders of hsematosis- effects which the beautiful experiments made by Dr. Faure have so clearly shown. The patient has received a death-blow, and although the mechan- ical obstacle which has been the primary cause of the asphyxia is removed, we are powerless in bringing on resuscitation. Now, children die in the same manner after convulsions which have recurred for several hours almost without interruption, and especially after that condition termed status convulsivus. Such repeated convulsions bring on a considerable disturbance of respiration and circulation. The face gets congested and becomes of a livid red hue; dyspnoea sets in and goes on increasing ; scarcely is one paroxysm over before another comes on, fol- lowed by a third, so that respiration and circulation have not time to resume their regular course. Hence, when the attack is over and quiet has been restored, even when respiration appears to be regular, it is a deceptive calm, and the patient dies within a few hours, although there have been no fresh convulsions, no marked dyspnoea, no manifestation of grave symptoms. He dies, if I may say so, not of asphyxia, but of the sequelse of asphyxia. The cerebral congestion, which is an effect and not a cause of eclampsia, may present a certain amount of gravity when carried to a very high degree. But although this accident has long been, and is still regarded by some as very common and habitual, it occurs, on the contrary, in very exceptional cases. Death by asphyxia is the usual mode of fatal termination of convulsions. In some cases, however, it must be admitted that the individuals die by syncope, whether this be explained by the considerable shock to the nervous system, or by convulsions of the heart impeding its action. Nothing is so difficult, to my mind, gentlemen, as to speak generally of prognosis in infantile convulsions. Prognosis in such cases is subordinate to a great many circumstances. From what I have said, you could see that inward convulsions are much riiore dangerous than violent convulsive seiz- ures almost exclusively limited to the limbs. With regard to the former, there are distinctions to make between incomplete convulsions in which there are only tonic contractions lasting beyond measure, and complete convulsions made up of alternate rigidity and relaxation of the muscles. INFANTILE CONVULSIONS. 807 As to the great seizures, they vary in regard of intensity, duration, and more or less frequent recurrence. In convulsions which come on at the outset, in the course, or at the close of certain complaints, it is of the highest importance to take into account the period at which they occur, as this influences prognosis considerably. I may here repeat what I have told you elsewhere. If we analyze the phenomena of which shivering consists, we find that it is, after all, a con- vulsion of a small degree. Whether it be partial or general, it is charac- terized by trembling and by involuntary movements of the parts which it affects, due to alternate contraction and relaxation of the muscles. It is not extraordinary, therefore, that these phenomena should be exaggerated in individuals whose, nervous system is excitable, as it is in children, and should even pass into a true attack of eclampsia. Hence, in infancy, espe- cially in cases of extreme nervous excitability, the slightest fever is ushered in by convulsions, whether the fever be due to a mere gastric disturbance or to some catarrhal affection, an intestinal or a pulmonary inflammation, or whether it be one of the prodromata of some continued fever. Such premonitory convulsions are most frequent at the outset of eruptive fevers, of measles in particular, and still more frequently of small-pox. In fact, they are so common in such cases, that some authors, and Syden- ham among others, have laid it down as an almost absolute law, that con- vulsions, occurring in a child who has cut his first teeth, should make one suspect the imminence of an exanthem. Sydenham, moreover, thought that such convulsions were a favorable symptom, showing that the eruptive fever would be mild. I am far from agreeing with him on this point. Although I admit that convulsions occurring at the outset of measles and small-pox are nearly always unattended with danger, I yet believe, first, that they give no indi- cation as to the future course of the disease, and secondly, that they may even prove (although in exceptional cases) dangerous complications, either from their violence and frequency, or from their seat; but what exception- ally renders them serious, is uncalled-for medical interference. How often non-professional persons, and even medical men, have recourse, in cases of infantile convulsions, to treatment which is always perturbing and too active. Leeches are applied behind the ears, in order to remove conges- tion of the brain, which is dreaded above all things, and the loss of blood, contrary to the end in view, brings the patient into a condition which is the most favorable for the production of nervous accidents. Or baths are had recourse to, cold affusions, the application of ice to the head, which, if the case be one of measles, for instance, increase the bronchial inflamma- tion which is usually present in such cases, and change into grave compli- cations these generally unimportant epiphenomena. Or, again, blisters are applied to the limbs, or cloths wrung out of boiling water ; and the pain caused by such brutal measures excites a nervous system, which should above all be quieted. If, on the average, convulsions occurring at the outset of diseases be gen- erally unattended with risks, the same thing cannot be said of convulsions which come on during the acute stage of a complaint, and a fortiori, toivards its close. They then indicate a fatal termination. Whether the case be one of pulmonary or intestinal inflammation ; or of measles, hooping-cough, or small-pox, convulsions occurring in the course or towards the close of the disease, point to a danger arising from some grave complication in the pa- tient's condition. The convulsive seizure is then preceded by brain symp- toms similar to those observed in typhoid fever; it recurs for two, three, or 808 INFANTILE CONVULSIONS. four days, lasting sometimes from a few minutes to a few hours only, and generally ushers in death. Such accidents are to be most dreaded in scarlatina. Even when they occur at the outset of this exanthematous fever, they have a much more serious import than when they come on at the beginning of an attack of measles or of small-pox; but when they happen in the third stage of scarlet fever, they end almost always fatally. They depend, in most cases, then, on the presence of general anasarca and concomitant albuminuria ; but they manifest themselves occasionally also independently of all serous infiltra- tion in the same manner as jactitation, delirium, vomiting, and other ner- vous disorders occur in the course of scarlet fever. Prognosis, in infantile convulsions, depends on other considerations, which a practitioner should be aware of, and should take into account, in addition to the seat and the course of the convulsions, and the period at which they appear in the course of various diseases. Clinical experience has made out the fact that convulsions are less dan- gerous in proportion as they are more easily excited; and what Stoll has said of children in general, may be applied to individuals of heightened nervous excitability: " Convulsio et spasmus, uti frequentior in inf antibus, ita minus periculosus iis plerumque est quam adultis." For there are indi- viduals, indeed, who are seized with convulsions for the least thing, and in whom no unpleasant consequences follow. Yet bear in mind that this nervous excitability may be hereditary, and that if in infancy it brings on eclampsia, it may subsequently manifest itself by producing very grave nervous affections, such as epilepsy. Recall to mind the cases which I related to you when on the subject of epilepsy, and remember especially that convulsions are accidents which expose med- ical men to the most unpleasant disappointments. Even those which come on under the most favorable circumstances may terminate fatally, and when- ever, therefore, you are sent for to see a child seized with eclampsia, be pru- dently reserved. From what I have just said, it might seem that a medical man should always interfere, and at any cost, in cases of infantile convulsions. I hold a perfectly contrary opinion. I very strongly believe that the less we do is in general the best we can do, and that our treatment should be expectant. If you question mothers whose children have more than once been seized with eclampsia, they will often tell you that they stopped the fit either by putting salt into the child's mouth, or by making him smell vinegar or dis- tilled orange-flower water, or by throwing cold water in his face, or by some other method as insignificant as the above. But because medical interfer- ence is rarely called for, it must not be inferred that we must stand with folded arms in all possible cases. In convulsive seizures we should cer- tainly be on the watch, although perturbing measures, such as bleeding, leeches, pretended revulsives to the skin, are always dangerous and almost never useful: it is essential, however, that the patient should never be lost sight of. If the progress, duration, and seat of the convulsions do not in- dicate danger, certain measures should be had recourse to which, without increasing the patient's risks, console his friends, sustain their hopes, and may gain for the medical man the credit of the cure. Some of these meas- ures are, besides, unquestionably useful; and antispasmodics rank first among them, such as ether, either alone or combined with musk or bella- donna, from 5 to 6 or 8 grains of musk, or from |-th to -|ths of a grain of belladonna. When the convulsions keep recurring, their cause must be above all ECLAMPSIA OF PREGNANT AND PARTURIENT WOMEN. 809 sought for; and it will be sufficient in many cases to remove the cause in order to cure the convulsions. The timely administration of an emetic and of a purgative enema has been known to stop convulsions due to embarrassment of the primce vice; in other instances the fit has ceased on removing the child's clothes, when a pin stuck in badly, or too tight a bandage, was the exciting cause of the seizure. But when the cause of the convulsions escapes us, or when it is beyond the reach of our active measures, as in eclampsia due to the pain of teeth- ing, and in certain symptomatic convulsions, there are still powerful and efficacious therapeutic measures which may be used against the convulsions when they are prolonged. Such are compression of the carotids and chloro- form inhalations. You are aware how prudently chloroform should be used, how you should keep your finger on the patient's pulse, counting the number and feeling the strength of the pulsations; and by taking these indispensable precau- tions you may be able to push on the inhalation very far. In the begin- ning of the year 1860, I was sent for to see a child, five years of age, the son of one of my best friends, who had on the previous day had a very slight attack of convulsions. He was afflicted with disease of the brain, which had arrested his mental development. I was sent for because he had been again seized with convulsions, which were this time awfully violent. When I saw him his face was congested to such a degree that he looked as if in the last stage of asphyxia. I made him inhale some chloroform poured on a handkerchief, which I held some distance from his nostrils, for a few minutes at a time, taking the precaution of constantly feeling his pulse. For six whole hours, from six to twelve o'clock, I thus administered chlo- roform almost without interruption, and I could not say how much I used. Thanks to this mode of treatment, the child, who was at the point of death, recovered, and is at present as well as he was formerly. I have raised, and still raise, my voice against the application of revulsives to the skin, and of blisters in particular, as they have seemed to me to do in general more harm than good. There are cases, however, in which these measures be- come necessary, and may be really useful, namely, cases of inward convul- sions which involve the diaphragm and the heart itself, are of the tonic kind, and are so prolonged as to bring on asphyxia or syncope. In such instances, a violent and rapid revulsion to the skin of the chest, such as can be produced by ammonia, may do good, by exciting irritation, which rouses into action those muscles the play of which is indispensable for the acts of respiration and circulation. LECTURE XLIV. ECLAMPSIA OP PREGNANT AND PARTURIENT WOMEN. Gentlemen : The details into which I entered, in our last conference, allow me to be brief in what I have to tell you to-day of puerperal eclampsia, apropos of a patient who lay in bed No. 28 in St. Bernard Ward. Were I to give you a detailed description of this affection, I should have to repeat, in a great part, what I said to you about infantile convulsions. This latter description was itself singularly like that of epilepsy; for, as I have more 810 ECLAMPSIA OF PREGNANT AND PARTURIENT WOMEN. than once told you, these affections present the greatest analogies to one another, if we merely look at their outward manifestations. Recall to mind' what happened in the case of the young woman who was in St. Bernard Ward; and those among you who witnessed her violent con- vulsive seizures could see how they resembled epileptic fits. These convulsions occurred under the following circumstances: On the day previous to her admission, the patient had been delivered, at three o'clock in the morning, of her first child. She had complained of nothing peculiar during her pregnancy. The midwife who was with her, gave her a full dose of ergot of rye after delivery, probably with the idea of stopping an abundant loss of blood. Convulsions came on two hours afterwards, and she was brought to the hospital in the course of the day. My clinical assistant, M. Moynier, on seeing her in the evening, decided on bleeding her at the elbow, to the amount of about 27 ounces. Still, the convulsions recurred with extreme violence from 6 to 12 o'clock p. M. They had ceased when I saw the patient on the following morning. The lividity of the face, which had on the previous day been carried to a very high degree, had almost completely disappeared. The tongue bore traces of having been bitten in several places. I prescribed the following mixture: R. Moschi, Ext. Valerianae, gr. x aa. Aquae Menthae, Syrupi TEtheris, " Floris Aurantii, §ss. aa. About 11 A.M., next day, she had another attack, as violent as the previous ones, and followed, like them, by profound stupor and complete loss of con- sciousness. The puerperal convulsions had in this case occurred at a period wheu they are not generally common, namely, after delivery. For, indeed, obstetric teachers tell us that eclampsia is rare before the sixth month of pregnancy, is less rare after delivery than during pregnancy, while it is most frequent during labor. In the present case, I could not make out the exciting cause of the seizures, and the only etiological condition to which I could ascribe them was that the patient was a primipara. The influence of a first pregnancy on the pro- duction of eclampsia (as a predisposing cause) is a fact admitted by most accoucheurs. According to Cazeaux, whose work is in everybody's hands, seven out of eight cases of eclampsia occur in primiparse. But although the influence of a first birth is so considerable, it must not be inferred that a woman who had passed through a first pregnancy and been delivered safely, is forever secure against puerperal convulsions, nor does the occur- rence of convulsions in a previous pregnancy necessarily imply their recur- rence in succeeding pregnancies. If you remember what I told you of epilepsy and of infantile convul- sions, it is unquestionable that the nervous excitability which, in some women, manifested itself during infancy by convulsive seizures, and later by hysterical symptoms or more less curious nervous disorders, is a pre- disposing cause which should engage the attention of the physician. I shall not review all the exciting causes enumerated in text-books, but there is one to which I am anxious to call your attention, although it was absent in the case of my patient,-I mean, albuminuria. I need not discuss here whether the albuminuria which occurs in preg- nancy be at the outset caused solely by compression of the kidneys, of the iliac veins, or the trunk of the vena cava inferior, by the uterus ; whether it ECLAMPSIA OF PREGNANT AND PARTURIENT WOMEN. 811 depends, as Braun, of Vienna, believes, on this compression, and the result- ing stagnation of the venous blood, and on the peculiar modifications which the blood undergoes during pregnancy; or whether it is due to the nervous disturbance which so often accompanies pregnancy. It has been sufficiently proved by clinical observation that albuminuria occurs pretty frequently during pregnancy, especially in primiparse, and- in women who have a malformed pelvis, whose uterus is too high up or is of considerable size, either from the presence of a very large foetus, or of seve- ral foetuses, or of an excessive quantity of liquor amnii. It is sufficiently proved also that this albuminuria has pretty frequently an unfavorable influence on the course of pregnancy, and on delivery and its consequences, and lastly, although it has been denied by some, that there is a relation, a coincidence at the very least, between albuminuria and puerperal convulsions. It should be added, it is true, that the coincidence is far from being constant. Albuminuria stands to eclampsia in the same relation as it does to ana- sarca. Although anasarca and albuminuria often coexist (and there is then an evident relation between them), the former may be present without the least trace of albumen being detectable in the urine, while, per contra, partial or general dropsy may be completely absent, and yet there be abundant albuminuria. In the same manner, although convulsions recur very frequently in women who pass albuminous urine (Mr. Imbert-Gour- beyre has met with it 94 times out of 159),* and although, consequently, the presence of albuminuria during pregnancy must make one dread the occurrence of eclampsia at a more or less distant period, it must not be forgotten that, in a great many cases, convulsions, never occurred, although the urine had for a long time been albuminous. Lastly, the case of the young woman which I have related, and other instances which have come under my observation, formally disprove the law which has been laid down by some, that in all cases of eclampsia occurring in women, the urine was invariably found to contain albumen. The urine of that young woman was examined on repeated occasions, and neither heat, nor nitric acid, ever gave rise to the least albuminous cloudi- ness. Most commonly, if not always, puerperal convulsions are general, as they were in the case which is still in the hospital. In some rare instances, however, they are partial, and the following case, which came under my care at the Necker Hospital, seems to me to present some analogies to this partial form of eclampsia. A woman 21 years of age, who had six months previously been delivered, at her full term, of the baby whom she was then nursing, was admitted into St. Anne Ward, and placed in bed No. 24, on January 16th, 1846. Her previous health had been good, but two months before delivery, she had been seized with convulsions, which had come on suddenly during the day, without any appreciable cause, and which, after affecting the whole left side of the body, left behind them incomplete hemiplegia, that lasted an hour. The patient was not unconscious during the attack. She was safely delivered, but two months subsequently, and this time during the night, she had another attack, which recurred three weeks later, consisted of several fits, and lasted from half an hour to an hour. The seizures returned after this every week at first, and then every day. From * De 1'albuminurie puerperale et de ses rapports avec 1'eclampsie (Memoires de 1'Academie royale de Medecine. Paris, 1856, t. xx). 812 ECLAMPSIA OF PREGNANT AND PARTURIENT WOMEN. December 28th or 30th, 1845, to January 16th, 1846, when I saw her, the attacks had returned nearly without intermission, and from that time, also, the left arm and leg had been paralyzed. She complained of having, in the affected limbs, a sensation unattended with pain, but which she com- pared to " something running over her legthe convulsions then began, first in the foot, then gradually extending up to the trunk, involving the arm and even the muscles of the face ; at other timqs, they spread from above downwards; and at other times, again, they were limited to the face. They consisted at first in tetanic rigidity and distortion of the affected limbs, almost immediately followed by convulsive jerks, and the paroxysm terminated in relaxation. Meanwhile, her health was good; she had a good appetite, and I could not find any other symptom of local disease either in the brain or in the thoracic or abdominal organs. Perhaps you will think, gentlemen, that the only connection which these seizures had with eclampsia was their having come on for the first time during pregnancy, and that they did not resemble puerperal convulsions, their form reminding one rather of partial epilepsy preceded by an aura. I will observe to you, however, that although they were epileptiform, these attacks differed essentially from epileptic fits in their mode of invasion and their course. The patient remained in the hospital until the following March. She was given strychnine at first, but narcotics were soon substituted for it, chiefly belladonna, which was given at once in 3-grain doses. The con- vulsive seizures gradually diminished in violence and frequency, and ceased completely by the 24th of February. The paralysis lasted longer; from the beginning of March, there was only a little numbness in the affected parts, and when she was discharged on March 20th, she had seemed to be perfectly cured for several days previously. To those who might regard this case as a kind of chorea, I will answer, that St. Vitus's dance presents neither this form nor this course; that the same may be said of chorea, or, if you prefer, of hysterical trembling; lastly, that if the case cannot be absolutely regarded as an instance of partial eclampsia, it cannot be referred to a well-defined nosological species, and can, therefore, be mentioned in connection with convulsions occurring in pregnant women. But I must return to the case of the woman in St. Bernard Ward. After her attacks of eclampsia, the last of which occurred on September 11th, she remained for 48 hours in a state of profound coma; on the 13th, during the night, she became delirious, and was so restless that she had to be confined with a strait-jacket. From the 16th to the 20th she was well, and seemed to have calmed down, there only remaining hebetude, which had persisted, when on the 21st, during my visit, she had an attack of acute mania. She began calling out, on a sudden, "My daughter! my daughter!" with eyes bright with excite- ment, and asking for her child, who had been taken away from her. She seemed to be unconscious of what she was saying or doing, and still had the look of hebetude which had never left her from the beginning. On my ward being cleared out in order to be cleaned, the patient was removed into another ward, under another physician's care, and soon recovered. Mania is a pretty common result of eclampsia, and there are instances on record in which the unfortunate women have continued in that state of maniacal delirium, and sometimes of more or less complete dementia. Generally, after an attack, the intellectual faculties are disordered for a longer or shorter period ; memory is particularly impaired, and sometimes lost completely, and the patients have no recollection, for several days, not ECLAMPSIA OF PREGNANT AND PARTURIENT WOMEN. 813 only of the seizure which they have just had, but also of the circumstances which preceded it. The loss of memory is sometimes partial only, and relates to certain subjects, such as forgetting the names of certain persons, even of those whom they see most frequently and who are dearest to them. Paralysis is one of the most frequent of the unpleasant sequelae of eclamp- sia, and it may be due to an organic lesion of the brain, such as hemorrhage into the meninges or the substance of the brain. The same thing happens here as in epilepsy. Note that, in both cases, the cerebral congestion, which is sometimes so intense as to result in hemorrhage, is no more the cause of the puerperal convulsions than it is that of the epileptic fit; it is an effect, and nothing more. I therefore do not include in the treatment of eclampsia, general or Ideal bleeding, intended to do away with this pretended cause of puerperal con- vulsions, no more than I advise them in epilepsy or in the eclampsia of children. Antispasmodics are, on the contrary, formally indicated in such cases, and chloroform inhalations rank first among them. There are already a pretty large number of cases in which chloroform has unquestionably done good. By its cautious use several times in succession, violent attacks have been known to be completely arrested, and convalescence to begin imme- diately. I shall mention in connection with this point cases published by M. Gros in the Bulletin General de Therapeutique, for January, 1849, which you will read with profit; and others, by M. Richet, in another periodical; while Dr. Campbell only recently communicated to me, among other cases which have come under his personal observation, the marvellous results which he had obtained by this method of treatment in the instance of a child, the daughter of a very high personage in the state. I will add, that many eminent accoucheurs (among whom I shall mention M. Blot by name), who had long opposed the use of chloroform in the treatment of eclampsia occurring during labor, now acknowledge, and strongly advocate, the use of this heroic remedy. I will, in conclusion, remind you that when eclampsia comes on in the eighth or ninth month of pregnancy, and has resisted all treatment, the induction of premature labor is adopted by most accoucheurs, a measure recommended by Stoltz, and approved of by men of the highest authority, among whom 1 need only mention Professor Velpeau and Dr. Cazeaux. When eclampsia occurs during labor, delivery should be hastened, if the attacks be violent, in order to save the mother and the child from the danger which they incur. Still, gentlemen, although the convulsions cease soon after delivery in the majority of instances, they continue to recur with renewed intensity in some cases, and quickly terminate fatally. 814 ON TETANY. LECTURE XLV. ON TETANY. Causes: the most Frequent are Nursing and the Puerperal State; Influence of Antecedent Diarrhoea ; Effect of Cold.-Description of the Disease: Three Arbitrary Forms.-Mild Form: Local Manifestations are alone Present, and the Symptoms are very Slight.-Intermediate Form: the Contractions become General, and. Spread from the Extremities to the Muscles of the Trunk and Face, while General Symptoms are Superadded to them.- Grave Form: Violence of the Convulsions.-A Fatal Case.-Prognosis generally not Grave. Pathological Anatomy very little known. Nature of the Disease.-Differential Diagnosis.-Treatment. Gentlemen : I shall devote this conference to the clinical study of a strange complaint of which I have had the opportunity of showing you instances in my wards ; and which has been in turn called intermittent tetanus, idiopathic contraction and paralysis, idiopathic muscular spasm, con- traction of the extremities, and, which I myself called at one time, rheumatic contraction of nurses, but prefer calling now, for reasons which I shall presently tell you, intermittent rheumatic contractions, and still better tetany. This complaint is in general of no gravity, although it sometimes frightens the patients who suffer from it, and misleads medical men who do not recognize it; and it is developed under circumstances which are so fre- quently met with, and under the influence of such common causes, that it must have always existed. Yet, whether it was unobserved, or rather whether the phenomena which characterize it were confounded with other forms of convulsive disorders, there is no description of it to be found in old writers; and we scarcely find, scattered through their writings, a few cases presenting some analogy to those which we observe nowadays. The his- tory of tetany dates, therefore, from our own time; and, indeed, it is only for the last thirty years, and especially for the last few years, that attention has been particularly directed to it. In 1831, a memoir was published by Dance, in the Archives Generales de Medecine, with this title: " Observations sur une espece de tetanos intermittent " (" Observations on a form of intermittent tetanus "). It was the first essay on the subject, and was soon followed by memoirs written by Tonnele,* Constant,f Murdoch,| and De la Berge.§ Since then tetany had henceforth a place assigned to it in text-books; or at least Rilliet and Barthez, in their special treatises on Diseases of Children, and Monueret and De la Berge, in the "Compendium of Practical Medicine/' * Memoire sur une nouvelle maladie convulsive des enfants. [Gazette MJdicale, t. iii, No. 1, 1832.] f " Observations et reflexions sur les contractures essentielles." [Gazette Medi- cate, p. 80, 1832 ; et Bulletin de Therapeutique, 1835.] J " Considerations sur les retractions musculaires et spasmodiques." [Journal Hebdomadaire, t. viii, 1832, p. 417.] I " Note sur certaines retractions musculaires de courte durge/' &c. [Journal Hebdomad air e des Progrts, &c., t. iv, 1835.] ON TETANY. 815 devoted important articles to it. In 1843 a memoir was published in the " Journal de Medecine," by Messrs. Teissier and Hermel, on Idiopathic contraction and paralysis in adults (" De la contracture et de la paralysie idiopathiques chez les adultes") ; and in the following year, Dr. Imbert- Gourbeyre, now Professor in the Preparatory Medical School at Clermont- Ferrand, chose for the subject of his inaugural address, " De la Contracture des Extremites " (Contraction of the Extremities). Numerous caseshad been observed, several of which had been published in various medical journals ; and I had myself collected a pretty imposing number of them at the Necker Hospital when, in 1846, my friend Dr. Delpech, then my clini- cal assistant, now my colleague, and Assistant Professor in the Faculty of Medicine, wrote a thesis on " Idiopathic Muscular Spasms," in which he summed up with talent all that had been done before, and added other cases to those already known. Six years later, Dr. Lucien Corvisart took up the same subject, and proposed the name of Tetany as a substitute for that of Contraction of the Extremities. In 1855, a communication from Aran to the Medical Society of the Paris Hospitals gave rise to an interesting discussion on the disease in question. Lastly, still more recently, Dr. Rabaud, house-physician to the St. Antoine Hospital, published his Recherches sur 1'Histoire et les Causes des Contractures des Extremites. The author of this monograph, however (which is lengthy and conscientiously written), committed the great fault of confounding together all kinds of contraction. The complaint of which I am going to speak, constitutes a very distinct species. The conditions under which it is developed, the causes which seem to bring it on, the form which it assumes, and its course, are all of them well-defined characters. As the first cases which I saw at the Necker Hospital occurred in women who had been recently confined and who were nursing, I at first thought that the disease was special to nurses, and I therefore called it Rheumatic Contraction occurring in Nurses; but it was not long before I found out, what others had besides said before me, namely, that nursing was not the only favorable condition for its development. It must be acknowledged, however, that nursing is, perhaps, the most frequent and active cause of intermittent contractions. I shall not attempt to explain why and how this is so ; but clinical experience establishes the fact, and, judging from what happens under our own eyes, its influence is unquestionable, since in that portion of St. Bernard Ward which is reserved for wet-nurses, and contains twelve beds only, we have always seen a greater number of cases of this complaint than in all the other wards. Menstruation, the puerperal state, and pregnancy especially, have been ascribed as causes; and one may admit that there is a connection between the phenomena of tetany and other nervous disorders which are so fre- quently met with in those intermediate conditions between health and dis- ease ; yet contractions occur not only in women apart from such conditions, but even in individuals of the other sex. They most commonly occur in young people, and in the majority of my cases, the patients' age ranged from 17 to 30. A woman, however, who was in bed No. 20, in St. Bernard Ward, was 46 years old. She had been delivered two months previously, and the symptoms in her case were rather marked. Instances of individuals thus affected are on record, who were 52 and even 60 years old. It is not uncommon to see the complaint in children, and even in infants from 1 to 2 years old; and you may recollect seeing a very remarkable case, that of a little girl 21 months old. She was the eighth child of a woman aged 30. Soon after birth she had 816 ON TETANL violent attacks of eclampsia, and was still subject to partial convulsions, consisting in spasmodic trembling of the upper eyelid and the globe of the eye ; sometimes in spasm of the glottis, which came on under the influence of emotion or of a feeling of annoyance, and was characterized by a pro- longed and whistling inspiration. Contractions of the extremities (phe- nomena of the same nature as the preceding) were very marked ; the thumb was forcibly adducted, and flexed into the palm of the hand under- neath the fingers, which were pressed against one another. There was oedema of the feet and of the upper limbs of the same degree. The child was of weakly constitution, and was suffering from membranous ulcerative stomatitis ; the exudations, which were of a grayish-white color, extended over her tongue ; and she had also had, for the last nine months, a cough, which for some time past had assumed a convulsive character. The process of teething, which so manifestly predisposes, either directly or indirectly, to convulsions, has been regarded as exerting an influence also on the development of tetany. But it may be conceived how difficult it is to appreciate such a cause as this, particularly as it is nearly always complicated with various pathological conditions, on which tetany would seem rather to depend. Of these pathological conditions, diarrhoea, especially when abundant and chronic, is the one which exerts the most striking influence. This exciting cause had at first completely escaped my attention. My friend Dr. Lasegue was the first who clearly pointed it out, and since then it has been mentioned by others, especially by Aran. Its influence is now admit- ted by all practitioners in the majority of cases, and you have been able yourselves, by questioning the patients, to ascertain that it is almost con- stantly present. Yet in a young man who was in St. Agnes Ward, contractions coexisted with obstinate constipation, and disappeared, on the contrary, when the bowels were freely acted on by purgatives. This patient was stout and well developed, a saddler by trade, and 21 years of age; he remained in hospital about five weeks. His complaint dated four years back. His health had been good until then, and he was seized suddenly, and for the first time, while travelling by rail. Although it was winter-time, he affirmed that he had not caught cold. He noticed suddenly that his fingers kept bent, and that he could not extend and use them. This lasted for two or three hours, and recurred every day for three months, his general health being, after all, unaffected. He was treated by bleedings, but immediately after each bleeding the contractions were not only more violent, but became general also, involving the muscles of the limbs, trunk, and face, to such a degree that his respiration was impeded and his speech embarrassed. In proportion also as the bleedings were repeated, the fits became more violent, so much so, that they were never so bad as after the fourth time of bleeding. Yet, by cupping him in twelve different places along the vertebral column, a perfectly different result was obtained, for the contractions disappeared for the period of ten months. After that time they returned, and then recurred every year, coming on every day for two months, and always at the end of winter. During the summer previous to his admission into the hospital, he had two or three attacks, transient only, and so slight that he was not obliged to give up his occupation. His general health was good all the while; he had a good appetite; but I wish to draw your attention to the fact, that his bowels, instead of being regular as formerly, were obstinately costive. By taking nearly two ounces of Epsom-salts, once a week, he managed to unload his bowels, and thus to remove his contractions for a time; but the costiveness ON TETANY. 817 returned as badly as ever, and his bowels did not act for four or five days. This is too exceptional a case to invalidate in the least the general law' which may be laid down regarding the influence of diarrhoea on the production of intermittent contractions. These may come on also after a severe illness, and in the cholera epidemic of 1854, I met with many cases in individuals who had suffered from cholera. They may occur after grave fevers, as typhoid fever in particular, as M. Demarquay (quoted by M. Imbert-Gourbeyre) and Dr. Delpech have recorded instances. Perhaps some may ascribe the disease in such cases to the intestinal flux, which is such a predominating symptom in cholera and typhoid fever; but I will remind them in answer, that contractions occur equally, although less frequently, in individuals who are convalescent from diseases in \vhich diarrhoea is not a usual symptom, or in which it is only a temporary epi- phenomenon of no great value; and that the muscular spasms must there- fore be more justly regarded as accidents of the same nature as the nervous phenomena, the paralysis, &c., which prolonged illness (grave fevers espe- cially) leave behind them, and which result either from a direct action of the morbid cause on the nervous centres, or from the nervous erethism which coexists with general enfeeblement of the system. Besides the above predisposing causes, there are some exciting ones which I shall point out to you. The influence of emotion, mentioned by authors, is very doubtful, in my opinion, at least as far as the first attack is con- cerned; for I admit that when a person is already subject to contractions, emotion may bring back an attack. A woman, 21 years old, who was in bed No. 11 in St. Bernard Ward, and who was seized with contractions in the fifth month of her pregnancy, had more violent attacks 'when under the influence of emotion. If this kind of causes should not be accepted without reserve, the same does not apply to cold, the influence of which has been pointed out by all observers, and which unquestionably acts not only as an exciting cause, but is sufficient by itself to bring on the disease. I will relate a few instances in point. A patient in St. Agnes Ward ascribed his complaint to his catching cold on going out one December day too thinly clad for the season, and he had felt the cold all the more keenly, that he was in the habit of working in a very heated room. Another, at No. 23 in the same ward, had spent the night out of doors in a state of drunkenness, and had been found the next morning in the state in which he was sent to the hospital from the police-station. A woman, to whose case I shall revert by and by, was seized with con- tractions after having, during winter nights, fetched water from the hospital yard. The cold had great influence on her, because she had been recently confined prematurely, was weakened by poverty, and by an obstinate diar- rhoea which had scarcely left her. Lastly, when I describe to you the phenomena which characterize con- tractions, I shall show you that compression of the affected limb brings them on very rapidly and without fail. It is no easy task to draw a sketch of this complaint, and the best de- scription cannot give you an idea of what you could not forget when you had once seen it. I will still endeavor to give you as accurate an idea of it as possible, and in order to enable you to see its principal features better, I shall speak of three distinct forms of the disease, although these divisions are in reality quite arbitrary. vol. i.-52 818 ON TETANY. In the first form, which I will call the mild form, there are only local manifestations, and they are as follows : The person has a sensation of tingling in the hands and feet, and then feels some hesitation, some impediment in the movements of his fingers and toes, which are not as free as usual. Tonic convulsions then set in, the affected limbs become stiff, and the will cannot completely overcome this stiffness, although it still struggles with it, and the patient can still use, within certain limits, the contracted muscles, move and even extend his fingers. The involuntary contraction increases, becomes painful, and is exactly like a cramp to which the patient compares it besides. In the upper limbs, the thumb is forcibly and violently adducted; the fingers are pressed closely together, and semi-flexed over the thumb in con- sequence of the flexion of the metacarpo-phalangeal articulation; and the palm. of the hand being made hollow by the approximation of its outer and inner margins, the hand assumes a conical shape, or better the shape which the accoucheur gives to it when introducing it into the vagina. This aspect of the hand, which you will most frequently meet with, is so peculiar that it is oftentimes sufficient by itself to characterize this kind of contraction. In some cases the index-finger is more powerfully flexed than the other fin- gers, and is partially bent under them; in other cases, the flexion is more general and complete. The thumb is turned into the palm and hidden by the fingers, which are themselves bent, and with such force that the nails leave an imprint on the skin; and they are so squeezed together, that in a case recorded by Dr. H6rard, sloughs actually resulted from the prolonged pressure. The thumb alone may be affected, while the fingers are scarcely contracted ; but such cases are rare, and it more commonly happens that the contractions spread to other parts, the wrist becoming flexed, and the hand turning forcibly inwards, the patient having lost the power of straight- ening it. In the lower limbs, the toes are bent down towards the sole, and press against one another, while the big toe turns in under them, and the sole becomes hollowed out in the same manner as the hand. The dorsum of the foot is strongly arched, and the heel pulled up by the contracted muscles at the back of the leg, while the leg itself and the thigh are in a state of extension. The contractions may affect the upper and lower limbs simul- taneously, or alternately; or they may be confined to one of them. In ex- ceptional cases the lower limbs are alone involved, while most commonly the hands are the parts that are affected. The convulsed muscles resist the efforts that are made to alter the position which they make the parts assume; and if their resistance be overcome, the fingers bend again as soon as they are let free, or, in exceptional cases, they keep the last position in which they are placed, although remaining contracted all the while. To the touch the muscles feel more or less hard, like tense and rigid ropes; but I have never, for my part, felt the fibrillary contractions which have been spoken of by some. The efforts made to overcome their resistance give the patient pain, although some relief is thus procured in certain cases. These tonic convulsions last uninterruptedly for five, ten, or fifteen min- utes, and sometimes even one, two, and three hours in succession; the sen- sation of formication then returns, and announces the termination of the attack in the same manner as it ushered it in. The affected parts become movable again, until, after a variable interval of rest, fresh paroxysms recur, the series of which constitutes the attack, which may be prolonged for several days, and even for one, two, and three months. So long as the attack is not over, the paroxysms may be reproduced at will, even though the patient has been free from them for 24, 36, 48, 72 hours, and more. ON TETANY. 819 This is effected by simply compressing the affected parts, either in the direc- tion of their principal nerve-trunks, or over their bloodvessels, so as to impede the venous or arterial circulation. I discovered this influence of pressure by chance. I was present when a woman suffering from contractions was being bled from the arm at the Necker Hospital, and I saw a paroxysm return in the hand on the same side when the bandage was applied round the arm. I at first thought that it was brought on by the venous congestion caused by the pressure on the vein; but on trying to account for the phenomenon, I found in other pa- tients that by compressing the arteries, the same results were produced. I have often since repeated the experiment, and as the contractions cease as soon as the pressure is removed, and the patient is therefore not much troubled, I have often made it in your presence. You saw then, that not only when the arterial or venous circulation was interrupted, but also when the median nerve was compressed in the arm, or the brachial plexus above the clavicle, the contractions came on, immediately preceded by the sensa- tion of formication, which is its first symptom. When the femoral artery is compressed, as when a ligature is applied round the thigh, or when the limb is firmly squeezed between both hands, and the sciatic nerve thus com- pressed, spasms of the muscles of the lower extremities are brought on, although with less facility. This phenomenon, which is already interesting by itself, is not besides without its practical utility; for it furnishes us with a means of diagnosis, as in no other convulsive disease are such effects pro- duced by similar means. It is an extraordinary circumstance that cold (which has so manifest an influence on the development of this complaint) should sometimes stop the contractions when applied to the affected parts. Thus it happens that, in a great many cases, patients suffering from contractions of the lower limbs have only to stand with naked feet on a stone or tiled floor in order to stop the convulsion almost instantly, and to regain the free use of their limbs. I have, in many instances, arrested paroxysms of contraction in the upper extremities, by making the patient dip his arms and hands into a basin of cold water. The arrest is only temporary, it is true, and the contraction returns when the part is no longer immersed. Intermittent contractions are generally preceded and accompanied by loss of muscular power. Movements of extension are not the only ones abolished by the convulsive contraction of the muscles; those of flexion are equally so. The fingers, for instance, when half flexed, no longer obey the will, and the patient cannot close them further. This rigidity is sometimes, in grave cases, carried to a very high degree; but even when it is slight, as in mild cases, and is added to the convulsive stiffness of the hands, it ren- ders the patients clumsy, and prevents them from freely using their hands ; if they are nursing at the time, they cannot attend to the child in the usual way, dress or even hold him in their arms. There is ancesthesia besides, and the sensations of formication, tingling, and numbness are referable to it. The sense of touch is more or less im- paired, so that the patients lose the faculty of appreciating the size and hardness of the objects which they take hold of, and which feel to them as if wrapped in some thick material. When they walk, they have the same sensation as if they were walking on a carpet. Now these alterations of cutaneous sensibility, the integrity of which is so necessary for the regularity of muscular functions, concur in impeding movements. I have told you already that these contractions are generally attended with pain, which is seated in the affected muscles, extends along the course of the limbs in the direction of the principal nerves, and radiate sometimes 820 ON TETANY. to the trunk. This pain, the presence of which by no means excludes anaesthesia, is often very moderate in the mild form of the complaint; and as, on the other hand, the convulsive phenomena are often very transitory, the result is that the patient does not complain, and, in some instances, chance alone makes us discover their ailment. This was the case, among others, with a woman who occupied bed 20 in St. Bernard Ward. She was admitted into the hospital for a diarrhoea of somewhat old date ; and if I had not, on going round the ward, witnessed myself an attack of contrac- tion in her hands, she would never have thought of complaining of an ailment of which she took no notice whatever. The case is perfectly different in the other two forms. In that of medium intensity, the violence of the pain and of the spasm is more marked; and the local manifestations are, besides, complicated with general symptoms, such as febrile excitement characterized by an ac- celeration of the pulse, malaise, cephalalgia, and loss of appetite. The fever, however, never runs very high, and is never accompanied by a marked heat of skin. Transient congestion happens in different parts of the body-in the limbs, the face, the eyes, and ears; sometimes they are accompanied by dizziness, obnubilatio, and tinnitus aurium. This congestive process sometimes causes swelling and cedematous puffiness of the limbs, which have been mentioned in several cases, principally in children. As to the contractions themselves, they are not only stronger than in the mild form, and return more frequently, but they are general also, instead of being confined to the extremities, and involve the muscles of the trunk and face, and sometimes also those of organic life. The spasms do not, as a rule, involve simultaneously the muscles of the trunk and extremities. The upper extremities are generally the first to be affected, and while the antecedent numbness and formication descended from the arm to the hand, the convulsions, following a reverse course, begin in the fingers', and successively extend to the wrist and elbow. The lower limbs are rarely seized before the upper. From the extremities, the contractions spread to other portions of the body, and the short time dur- ing which they last in a given part, in fact, the mobility of the complaint, is a character of which I shall make use when I come to speak of its na- ture. The abdominal muscles may be affected, and, in a case published by Dr. Herard, the recti muscles stood out like two very tense cords. Instances have also been recorded in which the spasm has extended to the bladder, and caused retention of urine. The pectorales majores and sterno-cleido- mastoidei have been seen to contract violently, and it is not uncommon to see tonic convulsions of the face. The patient's aspect is then very peculiar, according to the set of muscles which are affected ; when the muscles of the eyeball are convulsed, strabismus results, either external or internal-that is, divergent or convergent. At other times the jaws are firmly clenched, and the embarrassment of speech may also be due to the tongue being involved. Deglutition is impeded when the pharynx is affected, and when the larynx is involved, the series of symptoms of thymic asthma are produced, as in the case of the little girl which I related at the beginning of the lecture. The laryngeal spasm, and the contraction of the muscles of the abdomen and chest, bring on more or less marked dyspnoea, which becomes extreme when the diaphragm is involved. The third and grave form of the complaint is characterized by the pro- longed duration of the contractions, their recurrence after short intervals, and their greater intensity. In the month of December, 1856, my colleague and friend, Dr. Lasegue, was consulted about a patient who was believed ON TETANY. 821 to be epileptic, at the Prefecture of Police, where he goes every day, as he is physician to the department for the insane there. The patient was that young man, 18 years of age, whom you afterwards saw at No. 13 in St. Agnes Ward, and to whose case I have already alluded. He had been found in the morning lying down in the streets, where he had spent the night in a state of drunkenness. All his muscles seemed to be in a state of violent contraction, and he was as stiff as a poker: he was perfectly con- scious, however; and although his speech was considerably embarrassed, through his inability to open his clenched jaws, he gave distinct answers to the questions that were put to him, and complained of great pain. The continuance of this general tonic convulsion, and the perfect preservation of the intellect, excluded at once all idea of apoplexy; while the character of the symptoms, and especially of those of the upper limbs (the hands being in the peculiar attitude which I have endeavored to describe to you), allowed Dr. Lasegue to diagnose the case immediately, so that he had him sent to the Hotel-Dieu. The interval between the intermittent paroxysms was very short. All his muscles, those of the trunk and of the cervical region, as well as those of the limbs, seemed to be simultaneously affected, and, unable to move at all, the patient fell down in a condition of tetanic rigidity. The contractions were very painful, and after a short time the breathing became embarrassed, from the tonic convulsion of the muscles of the chest, abdo- men, and diaphragm, the larynx itself not being spared. The face became red, and the lips livid; the veins swelled, and, during this fit of awful dyspnoea, attended with pulmonary engorgement, as in epilepsy, or better as in tetanus, suffocation was to be dreaded. Fortunately, this state of things lasted a very short time only. You have more than once witnessed these attacks, when going round with me. They came on suddenly, ushered in by a sensation of formication, and lasted several minutes, sometimes for a quarter of an hour, or even half an hour. The mind of the unfortunate patient was perfectly clear, and he could speak, although the contracted state of the muscles of the jaws em- barrassed his speech considerably; even in spite of his pain he was somewhat cheerful. When the attack was over, he got out of bed and went on with his occu- pation, rendering slight services to his companions, and acting as sick at- tendant. In the intervals between the attacks his general health seemed by no means disturbed. The attacks, however, left behind them lumbar pain and a feeling of contusion (in the joints chiefly), and a state of weak- ness and prostration which lasted for some time. On several occasions I noted some fever. The seizures became by degrees more rare, and after remaining a month and a half in hospital he wished to go home. But six weeks afterwards he was seized in the same manner again, and was readmitted into the Hotel- Dieu, under the care of my esteemed colleague, Professor Rostan, in whose ward he died of pulmonary consumption. The tubercular disease remained latent to the last, and was not revealed by stethoscopic signs; this peculi- arity was dwelt upon in the notes given me of this patient's case; the gen- eral debility, cough, and habitual dyspnoea alone caused it to be suspected. On a post-mortem examination, the lungs were found to be infiltrated with tubercles, and the spinal cord to be slightly softened at its upper part. I shall return to this case presently, when I tell you my views of the nature of tetany, and speak of the relations between it and the anatomical lesions which have been found. I will then tell you that the convulsive seizures in this case were by no means due to the tubercles, of which no material manifestation was found in the nervous centres, and that the soft- 822 ON TETANY. ening of the cord should be regarded not as the cause but an effect of the disease. I shall enter into explanations on this point, which I have besides dwelt upon in our conferences on apoplexy and on convulsions. I do not admit the supposition that the contractions were in this case due to the tubercular diathesis, and this cannot be put forward in the fol- lowing case observed, in M. Cullerier's wards, by Dr. Blondeau, whilst a resident assistant at Lourcine Hospital. Elizabeth B , aged 28, was admitted January 20, 1848, into St. Mary's Ward, No. 32. She was in the eighth month of pregnancy, and was suffering from syphilis, with numerous ulcerated mucous tubercles in the external organs of generation. She had, besides, a very copious and obsti- nate diarrhoea. She was in a state of considerable weakness and maras- mus, and on February 13 she was delivered of a stillborn child. Two slight contractions of the uterus, which were scarcely perceived, were sufficient to expel the foetus. The diarrhoea ceased at last, on the administration of nitrate of silver injections. It was completely arrested five days after de- livery ; the appetite became good again, all the digestive functions regular, and a marked improvement of the general condition of the patient was ob- served from day to day. She had even regained her strength and a certain amount of flesh, when she was seized, on February 27, with symptoms which terminated fatally. She complained in the morning of some swelling of the feet, and ex- pressed a fear that she might be again paralyzed, as she had been on a former occasion. She added, however, that she felt well, and indeed, apart from this slight swelling of the lower limbs, nothing was found which called at- tention. On the following night she had a violent pain in the head, and the next morning she was seized with tetany. Her hands and feet were violently convulsed, and her fingers and toes serniflexed, in the attitude which I need not again describe. The muscles were so contracted that all efforts to overcome their resistance proved use- less. The muscles of the face were involved, the jaws were convulsively clenched, and speech was embarrassed. The patient, however, still answered the questions that were put to her, and her intellect was perfect; as the muscles of the neck and chest shared in this general convulsion, respiration was impeded, and the face red and congested. It was then ascertained that the patient since her delivery, and even when her diarrhoea had scarcely stopped, had on several occasions got out of bed during the night, and fetched water from the fountain in the hospi- tal yard. On the night of February 27 she again committed the same imprudence, and it was after this that the symptoms, which were already imminent the preceding day, manifested themselves with awful violence. She looked on the point of choking, and cerebral congestion was also to be dreaded. She was immediately bled from the arm, but four hours after- wards Dr. Blondeau was sent for; the contractions had diminished in the limbs, but the symptoms had become worse in regard to respiration. The muscles of the neck and face were more violently contracted than in the morning; the livid face, the fixed eyes, the anxious breathing (which had already become 'stertorous), the uncountable pulse, pointed to asphyxia carried to the highest degree, and to imminent death ; and yet, in the midst of this storm, the patient seemed to retain her consciousness. Twelve leeches were ordered to be applied behind the ears, but two or three had scarcely taken before the patient died. On making a post-mortem examination, all the viscera were examined with the greatest care, and no other appreciable material lesion was found ON TETANY. 823 than traces of congestion in the meninges, the veins of which contained a little more dark blood than usual. This is the only instance, gentlemen, in which I have known idiopathic contractions terminate in death, for the young man whom you saw in one of my wards, and who subsequently died under Dr. Rostan's care, died of tubercular consumption and not of his convulsive affection. Notwithstanding the fatal case which I have just related to you, the prognosis of tetany is not grave. Even in its most severe forms, when the symptoms have sometimes become apparently serious, and have excited fears that death might occur, I have never seen a single patient die, and I have by this time seen a very considerable number of such cases. After the complaint has lasted a variable period, from several days to one, two, or three months, the patient gets well, even when he has not un- dergone treatment; and the attacks, which leave behind only lumbago and transient weakness, do not seem to affect the system deeply, or to impair the general health. Pathological anatomy has necessarily done very little in this complaint; but, from a mere review of the symptoms, it is impossible to admit that such mobile and transitory phenomena can be due to the existence of se- rious organic lesions. Those which some authors, Dr. Imbert-Gourbeyre among others, have regarded as the causes of idiopathic contractions, be- longed to the diseases of which the individuals died, and in the course of which the convulsions had developed themselves. Some degree of cerebral congestion was, it is true, found in the woman who died under Mr. Cul- lerier's care; but it was an effect not the cause of the convulsions, or rather of the asphyxia, which had brought on death. In the case of the young man who had been in my wards, the softening of the spinal cord was itself a secondary change analogous to those met with in convulsive diseases- facts to which I have sufficiently called your attention in connection with epilepsy. Intermittent contractions have, therefore, been justly classed with neu- roses, and regarded as a convulsive neurosis, like epilepsy, eclampsia, and hysteria, although we know less of their nature. Yet the conditions which are favorable for their development, the evident influence of cold on their production, the suddenness with which the symptoms that characterize them come on, the mobile and flying character of these, the intermission between the attacks, induce me to believe that they are of a rheumatic nature. In support of this view, in which they concur, several medical men have pointed out the coincident existence of rheumatism, and have insisted, as I have done myself, on the presence of a buffy coat on the blood drawn in such cases. This last argument, however, is perhaps of less value than we have ascribed to it. I shall not dwell on the differential diagnosis between tetany and other forms of contractions, because, from what you have seen yourselves and what I have told you, it seems to me difficult to confound this complaint with any other. In the grave form alone, and the form of medium inten- sity, one may be for a moment in doubt, because he may, at first sight, think that the case is one of idiopathic tetanus. But while in this latter affection, the convulsions, whether they be regularly tonic or mixed up with clonic convulsions which preceded them, begin first in the muscles of the jaws, those of the face (producing trismus), and those of the trunk, and only by degrees extend to the extremities simultaneously, rheumatic contractions run an opposite course. It rarely happens, moreover, that the muscles of the extremities and those of the rest of the body are affected at the same 824 ON TETANY. time ; lastly, the circumstance that it may be provoked by compressing the limbs is an important character, pathognomonic of the complaint. I shall not speak of the differential diagnosis between tetany and con- tractions depending on cerebral or spinal diseases, the analogies between these being only very remote. Besides, symptomatic contractions are generally limited to a certain number of muscles exclusively, and are pre- ceded or accompanied by a group of phenomena,-such as disorders of the intellect, impairment of sensibility, persistent paralysis, and febrile symp- toms,-which essentially differ from what we observe in tetany, in which local manifestations, having themselves very special characters, are every- thing. If you recall to mind what I told you of epilepsy, either in its convulsive or its partial form, you will understand why I do not dwell on the diagnosis between it and tetany, for, to my mind, it is attended with no difficulty. The retention of the intellectual faculties in cases of general contractions, carried to the highest degree, is of itself sufficient to enable one at first sight to recognize them from an epileptic fit, and doubt is possible in such cases only. Now what should the treatment of tetany be? Bloodletting seemed to me from the beginning to be formally indicated, with the view of combating the congestion, which considerably alarmed me in the first cases which came under my notice. Although my premises were wrong, I was thus led to apply a method of treatment which even now renders me the greatest services. Chiefly when the patient is of a vigorous constitution, and when there is very marked febrile reaction, I have recourse to bleeding from the arm, and to cupping of the spine. Whatever be the mode of action of this plan of treatment, its good results cannot be called in question, and I cannot be suspected when I advocate it, for you are aware that there are few men who are as chary of bleeding as I am. When I afterwards thought that this neurosis was of a rheumatic nature, I admin- istered quinine, which is acknowledged by most practitioners to be efficacious in the treatment of rheumatism. Although I obtained some really good results from it, they were not, however, to be compared with those of blood- letting. But there are cases in which bleeding is not admissible, and treatment must then consist chiefly in the administration of quinine. Thus, when the patient suffering from idiopathic contractions is of a weakly constitution, or has been debilitated by a chronic diarrhoea (as was the case in the woman whom you saw at No. 20 in St. Bernard Ward, and who nursed twins, of whom she had been delivered only a month before), bleeding would be productive of fatal consequences, so that the intercurrent accidents should be combated, the exhausting discharge arrested by all means, and, as soon as the stomach can bear it, quinine is to be given. Opium and belladonna, in small doses, are useful adjuncts of bloodletting or of quinine. In the grave form of the disease, and in violent paroxysms, as those of the woman in Lourcine Hospital, chloroform inhalations (practiced'with all the prudence demanded by such a potent drug and by peculiar idiosyn- crasies) are indicated, as in convulsions in general. The young man who was in St. Agnes Ward begged for them himself during his fits, so great were his hopes of obtaining relief from it; and however temporarily it might be, yet chloroform never failed to relieve him. Lastly, gentlemen, you will find in the Bulletin Therapeutique for March, 1860, a case reported by my regretted friend, Dr. Aran, of idiopathic contractions of the extremities cured by local applications of chloroform to the contracted muscles, simulta- ON CHOREA. 825 neously with its internal administration, in doses of four or five minims every hour, in acacia mixture. Aran appends to his case certain remarks which should be borne in mind. It should not be forgotten, he says, that chloroform irritates the skin very much ; and, consequently, too large a quantity of the fluid should not be used in persons with a fine and delicate skin. A piece of fine linen impregnated with chloroform is alone required, and it is not even necessary that the whole piece be moistened, but only the part which is in contact with the contracted muscles. He also suggests that in women with a very fine and delicate skin, some advantages might be gained by using chloro- form mixed with an equal or double the quantity of oil of sweet almonds, or of camphorated chamomile oil. At all events, the piece of linen should be kept in situ by means of a few turns of a bandage, so as to make sure that the affected parts are in contact with the chloroform. LECTURE XLVL ON CHOREA. Gentlemen : Those among you who have for some years continuously attended my clinical lectures have seen, in our male and female wards, patients suffering from convulsive affections, characterized, all of them, by muscular agitation, more or less disorderly and strange movements and con- tortions, and to which the generic term chorea (from the Greek word X»pst.a, a dance) might perfectly be applied. Quite recently we had three women, at the same time, in St. Bernard Ward (one, 21 years old, at No. 2; another, a young girl, 16 years of age, at No. 30; and a third, aged 19, at No. 31a), who were all suffering from the same complaint, which had, however, set in under very different cir- cumstances ; while these very same symptoms were present in a young man, 19 years old, lying in bed No. 4. St. Agnes Ward. You were, at first sight, struck with the look of hebetude and imbecility of this young man. He was constantly making grimaces, grinned for the least thing, and answered badly the questions put to him, seeming scarcely to understand them. The impairment of his intellectual faculties was, however, much more apparent than real; for it was the constant convulsive agitation of the muscles of his face which gave him that imbecile look, and the grim- acing and grinning aspect which immediately attracted your attention. He kept also making disorderly movements, strange contortions, which were most marked in the extremities, chiefly in the arms. At Nos. 8 and 9 in the same ward you could see two men-one aged 51, a hatter, in whose trade the acid nitrate of mercury is used for milling the felt of which hats are made ; the other a house-painter, who affirmed that he had never had painter's colic or any other symptom of lead-poisoning, but who confessed that he was in the habit of drinking brandy every morning fasting, in quantity not sufficient to make him drunk, but, accord- ing to his own expression, sufficient to excite him. Both these men were affected with general trembling of the upper and lower limbs, which was so great in the case of the patient at No. 9 that he could not stand, even by holding on to his bedpost; he could scarcely eat, from the difficulty he 826 ON CHOREA. had in carrying his food to his mouth, and he spoke with the greatest dif- ficulty, from his tongue itself being involved in the disease. Again, in bed No. 6, St. Bernard Ward, there was a girl 13i years old, who was likewise affected with a convulsive agitation, which had manifested itself subsequently to accidents, of which she gave the following account. She enjoyed good health ; she had menstruated, for the first time, eighteen months previously; and there had been no irregularity of this function, which had been at once established properly. She had never had hysteri- cal fits, although she laughed and cried without a real reason, was fright- ened about nothing, and presented all the characters of a nervous mobile temperament. About sixteen months before the complaint set in for which she came into hospital, she had had typhoid fever of six weeks' duration, which had left behind it constant headache, to which she had not been previously subject. Five weeks before her admission she went to work as usual, but during the course of the day she was seized with convulsive movements of the arms and legs, which were after all rather moderate, for she went on with her work. The movements became more violent the next day, and were accompanied by other phenomena. She had, without cause, paroxysms of wild joy, which did not calm down even on her visiting her sick mother, and although she was deeply moved ; on the contrary, her demonstrations of joy became more and more wild in the course of the day. She went to work again the next day, and kept on working as usual, in spite of the constant agitation of her arms and hands; but about 11 o'clock in the morning more serious symptoms manifested themselves. She turned suddenly pale, and nearly lost consciousness. As this state lasted, she was taken home; she then complained of shivering, and a general sensation of cold, which made her shake all over and her teeth chatter. She had a complete syncope at 4 p.m., soon followed by convulsions violent enough to require a strait-waistcoat to restrain her. This attack lasted an hour and a half, during which time she was delirious, alternately singing and crying out fiercely, and frightening all the people in the house. Her face was red and swollen, and she looked haggard. She was then brought to the Hotel-Dieu, where the attack quickly subsided spontaneously, leaving after it the convulsive agitation of the muscles which we saw. As the patient lay on her bed, these convulsions consisted in alternate movements of flexion and extension, recurring continuously, and always in the same direction. If she were asked to take hold of an object shown to her, even when of small size (as a pin, for instance), she contrived to do it, moving her hand towards it in jerks, but without difficulty, and in a straight line. She never dropped the pin when she had once seized it; and although she continued to shake, she could fix it in her dress. She could feed herself also, and easily guided the spoon from her plate to her mouth; whilst the man at No. 9 in St. Agnes Ward could not do this, nor the young man at No. 4, nor the three patients at 2, 30, and 31a in St. Bernard Ward. The first thing which unquestionably struck you, gentlemen, in all these cases, was the presence of choreic movements ; but before inquiring into other elements of diagnosis, apart from this common character, a moment's attention already enabled you to catch such distinct differences in the mus- cular agitation and the involuntary movements which characterized it, that you could not only recognize well-defined species belonging to the genus, but were also led to conclude that some of the species belonged to very dif- ferent pathological genera. Thus, while the young women lying respectively in beds 2, 30, and 31a, in St. Bernard Ward, and the young man in bed 4, St. Agnes Ward, were ON CHOREA. 827 affected with that kind of chorea which, since Sydenham, has been called St. Vitus's dance, the young girl at No. 6, in the female ward, suffered from an hysterical choreiform affection ; the two men at 8 and 9 in St. Agnes Ward had, the one alcoholic chorea, and the other mercurial chorea-or, if you like, trembling, a term applied to those species of chorea in nosolog- ical tables. I have been accused of changing the meaning of the word chorea, admit- ted by every one, it is said, to designate what I call, after Sydenham, St. Vitus's dance, and of thus confounding with chorea, properly so called, vari- ous choreic affections, such as tarentismus, hysterical dansomania, hysterical chorea, and trembling, which nobody ever thought of mixing up together. My answer is, that I am not the only one who has taken in its widest acceptation an essentially generic term. As to the confusion which is laid to my charge, I will endeavor to put you on your guard against it (pre- cisely because I too often see medical men commit that error), if not by describing to you all the species of chorea, some of which besides, such as the epidemic choreomania of the Middle Ages, and tarentismus, are almost unknown now, but by passing some of them at least in review, and especi- ally by speaking to you of St. Vitus's dance, to as great a length as the nature of this course admits, and by pointing out the characters which distinguish it from other choreiform affections. St. Vitus's Dance-Chorea Sancti Viti, Sydenham. Reason ivhy the term St. Vitus's Dance appears to me better than that of Chorea. -Predisposing Causes: Age, Sex, Hereditary Influence.-Pathological Conditions: Chlorosis, Tubercxdar, and Strumous Diathesis, Rheuma- tism.-Exciting Causes: Emotions, Fright.-Description of the Disease.- Antecedent Phenomena.- Convulsive Phenomena.-Their Specific Char- acter.-Paralysis.-Disorders of Sensibility.-Impairment of the Intel- lectual Faculties.-The Complaint is usually Curable.-Its Mean Dura- tion.-It may terminate in Death, and hoxv.-Pathological Anatomy throws no light on it.-Influence of Intercurrent Febrile Diseases on the course of the Complaint.-Relapses and Recurrences: their Duration is less than that of the Previous Attacks.-Treatment: Cold and JVarm Baths, Sulphur Baths, Gymnastics.-Internal Remedies: Tartar Emetic, Strychnine, Opium in large doses in grave cases, Hygienic Measures. Gentlemen : It is beyond question, especially since the beautiful his- torical researches made on this point by Messrs. G. See and Roth,* and some others, that the name St. Vitus's dance was at first given to a singu- lar disease, very different from the one which we now know, and which was epidemic in several German villages at the end of the fourteenth and the beginning of the fifteenth century. This name was applied to it because individuals suffering from this choreomania-a regular ecstatic frenzy, to which that of the convulsionists at St. Medard has been compared- went on a pilgrimage to St. Vitus's Chapel, at Dresselhausen, in the dis- trict of Ulm, in Suabia, as the Saint was said to have the power of curing them, just as in our own time other saints are said, in popular' legends, to possess an analogous power in other complaints. Whatever its origin, the name St. Vitus's dance, perverted from its original meaning, was given by * Germain See, " De la Choree" (Mem. de 1'Acad. de Med. 1850, t. xv, p. 373). Both, " Histoire de la Musculation irresistible " (Paris, 1850). 828 ON CHOREA. Sydenham, who did not pique himself on being an erudite, to the com- plaints of which I am now speaking; and from having been adopted by the authors of the eighteenth century, it is now understood by every one. It has been adopted in your very text-books, and there given as synony- mous of chorea, a generic term which Bouteille proposed, in 1810, to sub- stitute for it; while it has taken such firm root in medical language, that all efforts made to restore its first meaning to it have failed. If this is to be regretted, in an historical point of view, science and prac- tice, I must hasten to add, do not lose much by Sydenham's mistake in eru- dition ; for it is to this great physician that we are indebted for the first truly scientific description of the symptoms of the complaint. For my part, now that everybody understands what is7 meant by St. Vitus's dance, this name appears to me the best-better than that of chorea, which, in its gen- eric acceptation, includes many things and specifies none, while the former term applies to one complaint alone and to the whole of it, as the rule is in sound logic. It has the immense advantage of designating the disease in question better than could be done by any other name constructed accord- ing to the principles of the most correct nosology: whatever be the ideas entertained of the nature of the disease, this name prejudges nothing, and all theories can conveniently adapt themselves to it. The same thing hap- pens in the case of this word as in that of all those words which mean*noth- ing in themselves but have been adopted by custom : ' they are the best, because they include a complete definition, and convey to the mind a com- plete idea of the object meant. So it is with the terms coqueluche (hooping- cough) and verole (pox), for instance, which, in spite and perhaps on account of their strange etymology, have become part of ordinary as well as of med- ical language, and which could not be replaced by any other term borrowed from a nomenclature having high pretensions to scientific accuracy. I now pass on to the study of St. Vitus's dance. Although a certain number of cases of this complaint may be every year seen in my wards where patients over 16 years old are alone admitted, such cases are rare when compared with those that are met with in children's hospitals; and I shall only tell you what you know already, when I say, that St. Vitus's dance is a complaint occurring in childhood and puberty, and generally from 6 to 15 years of age. It is only exceptionally that it affects children before they have changed their first teeth, and it is much more common to see it in individuals who have attained the age of puberty, up to 25 years. There are even instances of chorea on record attacking older persons; and M. G. See has seen it in a woman 36 years old, in another 44 years of age, and in a man aged 59. Jeffreys saw7 it in a patient 60 years old, and Powel and Maton in another 70 years old, while Bouteille saw7 a man aged 72 who was afflicted with it; and lastly, only recently Dr. Henri Roger has recorded a case of chorea occurring in a lady 83 years of age. This last case is so interesting, on account of its singularity, that I must beg permission to read it to you in full: " Mrs. , 83 years old, has as strong a constitution and as clear a mind as may be expected at her advanced age. Apart from some weakness in the legs and palpitations of the heart, of which she has complained for about the last ten years, unaccompanied by murmur and by marked precordial dulness, and without a history of antecedent acute articular rheumatism, except also a rather obstinate constipation, and some vague rheumatic pains in the loins and the limbs, her health is at present as satisfactory as possi- ble. I must mention, however, that eight years ago, I attended Mrs. for an attack of pleurisy w'ith effusion on the right side ; and two years ago ON CHOREA. 829 for sciatica, which was of moderate intensity and duration ; and last year for cerebral congestion, which disappeared after a few days. " On the 15th of May last, I was sent for to see Mrs. and easily recognized chorea. For three or four days previously only, she had felt, without any appreciable cause, any intense emotion, or other premonitory symptoms, some uncertainty and exaggeration in the movements of her right arm and leg. These two limbs, when I saw her, were the seats of other marked movements ; the arm was, at very short intervals, moved suddenly and with a jerk; when, in obedience to the patient's will, it was drawn forwards, it was soon pulled backwards or dragged more forwards by involuntary contractions; its movements were strange, irregular, and badly co-ordinated. The same thing occurred with the leg, which, although it lay on the bed, was dra\vn up by a sudden contraction, in such a man- ner that the foot was thrust at haphazard in various directions. " When asked to do so, the patient could, by an effort of the will, stop these movements, but they began again almost immediately. Their uncer- tainty and irregularity increased still more when the patient was up. She could scarcely keep on her legs, and was compelled to sit down instantly. With some care, and with time, she managed to feed herself. The face was only slightly distorted, from the muscles of the face being less frequently and less violently contracted than those of the limbs. Speech was nearly natural, and was interrupted at rare intervals only. " The muscles of the walls of the chest and abdomen were not the seats of special contractions. The senses were not markedly affected. The pa- tient complained of a sense of fatigue all over, owing to the exaggerated motility. General sensibility was neither diminished noi- exalted ; Mrs. was lowspirited, or rather had grown inpatient, on account chiefly of hdr sleeplessness, although she had some sleep, during which the chorea ceased. The animal functions (digestion, circulation, urinary secretion) were nor- mally performed. These details sufficiently prove the existence of idio- pathic chorea: the disease, let it be added, was at first moderately intense, but increased in violence after three or four days. The movements became more incessant and more violent, were almost more marked in the arm and leg, and exclusively limited to the right side. The patient could not feed herself, and was not able to walk, while the chorea persisted during nearly the whole night, and prevented sleep. The disease continued in this degree until June 1, that is to say, for about a fortnight. From that date it decreased by degrees, and on June 15, namely, after five weeks, the patient got perfectly well. During the whole time there was no impairment of the general health, and there was no concomitant phenomenon deserving of notice, except the coexistence of neuralgic pain along the course of the arm, on a level with the insertion of the deltoid and about the elbow (with- out swelling or redness of the parts, and without fever). " The treatment was simple. It consisted in the internal administration of oxide of zinc and of powdered belladonna, in gradually increasing doses of from 5 to 15 grains of the former, and from 1 to 2 grains of the latter. Local applications of chloroform diluted with water (1 part to 30) were used, and calmed the pain in the arm, which was the seat of the choreic move- ments, and the limbs were rubbed and kneaded, especially the leg, which was not painful." An analogous case is reported in Graves's " Clinical Lectures." The chorea was very violent, and the patient was a Dublin chemist, 70 years of age. Dr. Henri Roger justly remarks that his patient was really suffering from St. Vitus's dance. " The complete integrity of the functions of the 830 ON CHOREA. nervous system before the setting-in of the convulsive affection, the ab- sence of all antecedent or subsequent cerebro-spinal disease, the unequivocal form of the symptoms (which were choreic and not choreiform), the dura- tion of the neurosis, which was almost the usual one in such cases, and its favorable termination," amply justify the diagnosis. These rare instances of St. Vitus's dance affecting individuals after puberty have almost exclusively occurred in women. Sex, therefore, plays in such cases a very important part as a predisposing cause; and this in- fluence of the female sex is very remarkable at the periods of life in which chorea most generally manifests itself, for statistics show that the proportion between girls and boys is as 3 to 1. This proportion is still higher after puberty, and it may be stated that St. Vitus's dance occurs exceptionably in males after the age of 15, while a pretty good number of cases of the disease in females might be cited. While on this point I must call your attention, gentlemen, to the fact that articular rheumatism attacks males more frequently than females, and that this tends to detract from the value of the opinion which holds that St. Vitus's dance is an expression of the rheumatic diathesis. I need not mention, as some authors have done, that the nervous tem- perament more than any other predisposes to this neurosis. Dr. G. See has done away with this commonplace remark, as well as with the influence of the patient's constitution. The same cannot be said of hereditary predisposition, which is unquestion- able; and even if judicious statistics had not proved it, it might have been asked why St. Vitus's dance should not be subjected to the same law as all nervous diseases in which hereditary predisposition holds such an important place. On inquiring into the family history of individuals affected with chorea, you will find that either their direct or collateral ancestors (of the latter, according to some, but for what reason I know not, no account should be taken) have suffered from various neuroses, such as hysteria, epilepsy, or eclampsia; or you will ascertain the existen.ee of certain diathetic manifes- tations, and in particular of the tubercular diathesis. And here, again, we have to deal with the question of the mutual transformation of diatheses, a great question of general pathology, to which I have already alluded sev- eral times. Several pathological conditions have been regarded as predisposing causes of chorea, but their influence for the most part is far from being proved. I do not stop to speak of the metastases of eczematous diseases- of the itch, of febrile eruptions, and of the metastases sequential to the sup- pression of habitual discharges-which have been too often erroneously enumerated among the etiological conditions of diseases the real cause of which escapes us; nor shall I say anything of gastro-intestinal disorders and of intestinal worms, which stand to chorea in a very doubtful relation of cause and effect, however marked their influence may be on the develop- ment of eclampsia. I will add that the impairment of the digestive func- tions-which, as I shall tell you presently, is a very common complica- tion of St. Vitus's dance-is a consequence of the perturbation of the whole nervous system arising from the disease itself, and should not be regarded as its starting-point. It is unquestionable that St. Vitus's dance has often a marked influence on the development of chlorosis. It is equally unques- tionable that a large number, the largest number even, of choreic women were previously chlorotic, and that they get well when they are cured of chlorosis by the measures indicated in such cases. It is evident that chlo- rosis is very often a concomitant condition, at the very least, which should ON CHOREA. 831 be taken into account in the treatment of St. Vitus's dance. I will go fur- ther : chlorosis, like all causes capable of weakening the organism and of producing erethism of the nervous system, plays an important part in the etiology of this singular neurosis. In pregnancy, which may be regarded as a favorable condition for the production of this nervous complaint, the latter should be ascribed to the chlorosis which so frequently accompanies pregnancy. No one denies this indirect influence of pregnancy on the pro- duction of St. Vitus's dance. Dr. G. See has collected sixteen instances of the disease occurring in women from 19 to 20 years of age, and my col- league, Dr. Horteloup, has seen one case'in a young woman aged 16. I told you a moment ago, gentlemen, apropos of hereditary predisposition, that St. Vitus's dance could be the manifestation of certain diatheses which had shown themselves in the direct or collateral ancestors of the patient, in their usual form. I would not go so far as to say, with J. Frank and Dr. G. See, that the tubercular or strumous diathesis plays an important part in the production of chorea, although a large proportion of choreic patients are also tubercular. The proportion which exists between other chronic diseases and tubercles should be first established. But of all these predisposing pathological states, rheumatism is assuredly the most marked and the least questionable. The relation of rheumatism, to St. Vitus's dance had been partially seen by Stoll, by Copland, by Bouteille, by Abercrombie, Begbie, Bright, Gabb, and Richard; while others, again, had pointed out the coexistence of pericarditis and endocarditis with chorea. Dr. Botrel went further in 1850, when he chose for the subject of his thesis, " Of Chorea considered as a Rheumatic Affection," and propounded the opin- ion, professed before him by Dr. Hughes, that the former complaint was only a special manifestation of the latter. But in his remarkable memoir on "Chorea and the Nervous Affections," &c., which, in 1851, gained a prize at the Academy of Medicine, Dr. G. See has brought out this fact so prom- inently, that the greater portion of this discovery really belongs to him. The interesting researches made by Dr. See, who is physician to the Hopital des Enfants, led him to the conclusion that in nearly every case of St. Vitus's dance, rheumatic pain had at least been complained of. Dr. See has not, however, guarded himself from exaggeration, and has con- founded under the same head, Rheumatic Affections, simple lumbago and muscular pain, which so frequently accompany the invasion of chorea. This law, however, when made less exclusive, is- an acquired fact in science, and there is no practitioner nowadays who has not been able to verify it. On several occasions, 1 showed you how it applied to cases that we saw together-among others to the case of a poor young woman in St. Bernard Ward, who was carried off by a most violent attack of chorea, which manifested itself ten or fifteen days after the setting-in of acute artic- ular rheumatism. About the same period I was asked by my colleague and friend Legroux to see with him the daughter of a tailor in the Rue Richelieu, who was suffering from an attack of acute and general articular rheumatism. We found endocarditis also; and the pain persisting ten or fifteen days after the outset of the rheumatic fever, St. Vitus's dance set in. It was moder- ate at first, but soon became complicated with awful muscular disorders, delirium, and lastly comatose symptoms; the girl died on the seventeenth day. Dr. E. Moynier published, in the thesis which he wrote for his doctor's degree in 1855, the following case, which I had communicated to him. A girl, 10| years old, has a first attack of chorea, after which she becomes hemiplegic. At the age of 14 she has rheumatic fever, and subsequently 832 ON CHOREA. a second but slight attack of St. Vitus's dance. Her brother, when 13 years old, had had rheumatic fever, and two months afterwards had been seized with the same convulsive affection as his sister. Their father had on five several occasions suffered from articular rheumatism, but never from chorea. A boy, 5? years old, is seized on January 1, 1859, with articular rheu- matism, which lasts a month. On the 1st of February following he had St. Vitus's dance, which was still present on March 7, when I saw him, and I recognized endocarditis, characterized by a rough cardiac murmur. I could add a good many more cases which have come under my own observation, and some of which are quite recent; for I never allow the opportunity to pass now, of inquiring into the law of coincidence, to which the labors of Drs. Hughes, Botrel, and G. See have called my attention particularly. Profiting by their researches, I have in many cases been able to foretell that children suffering from rheumatism would become affected with chorea. On the other hand, I have been able to predict that choreic children who were brought to me would, sooner or later, have rheu- matism. Yet you will rarely see it precede rheumatism, while it often follows it, in the proportion of one-third of the cases. This proportion, which is nearly the one given by Dr. G. See, may, per- haps, seem exaggerated, if cases of purely articular rheumatism be alone reckoned; but the great pathological law laid down by my eminent col- league at the Charite Hospital, Dr. Bouillaud, namely, the law of coinci- dence between cardiac affection and rheumatism, comes here to our help. For, if you do not find articular rheumatism in a pretty large number of choreic patients, you will find the signs of old endocarditis, a manifestation of rheumatism which spared the joints, but existed nevertheless, and affected the organism deeply. Allow me to relate to you a case which you saw with me. A girl, 14 years old, who had never menstruated, was admitted into the clinical wards on January 9, 1861, for St. Vitus's dance, affecting chiefly the left side. She had been ill for twelve days, and gave us very incom- plete information as to her previous history. I found out, however, that when a child she had had choreic movements and articular pains. Her face wore a very marked expression of hebetude; she could scarcely speak, and her lips moved in a singular manner. When she tried to speak, she protruded her tongue out of her mouth in jerks ; and when she drank, she swallowed the liquid spasmodically. She could scarcely walk; her left arm and hand and her left leg were shaken in a disorderly manner; she was obliged to keep in bed, and could not feed herself. Sensation was diminished on the left side, both in the face and limbs. There was no in- testinal disorder; respiration and circulation were normal; but over the cardiac region, especially at the apex, there was heard a soft systolic blow- ing murmur, which did not extend into the bloodvessels. On January 16 she had on the limbs velvety eminences, like those of urticaria; on the 17th she had fever, characterized by a frequent pulse and heat of skin. She complained of rheumatic pain in several joints, and there was marked effusion into the right knee. The cardiac blowing mur- mur was more distinctly heard and more prolonged. For seven days, several articulations were attacked with rheumatism, which left them to return again after a time, and meanwhile the choreic movements nearly disappeared. On January 25 the aspect of stupor was very marked ; the expression of the face never varied, and the pupils were dilated. The child lay on her back, scarcely complaining of pain in the joints, and she had convergent strabismus. There was, however, marked ON CHOREA. 833 diminution of the pulse and of the respiratory movements. Since January 20 the digitalis had been stopped, which had been administered for several days, without producing any perceptible modification of the heart's pulsa- tions, which until then had been frequent, and been felt over a broad area, as they usually are in rheumatism. The frontal headache, the strabismus, stupor, diminution of the movements of the heart and of respiration, the nearly complete cessation of the pain in the joints, were sufficient indica- tions that rheumatism had attacked the brain; yet the cerebral macula only became manifest on January 26, but very conspicuously. There was constipation also. The brain-symptoms persisted during fourteen days, the pulsations of the heart had become less and less frequent (48 per minute), and the breathing was slow, sometimes interrupted for a few seconds. Four ounces of coffee a day had at first been given, and subsequently calomel, in divided doses. On February 4, that is, fourteen or fifteen days after the onset of the cerebral rheumatism, all the brain-symptoms im- proved ; there was less stupor, the intellect was clearer, the strabismus less marked, the pupils less dilated, and the patient answered questions readily, while she had not been able to do this for several days. The pulse became more frequent, and the respiration more regular; the face no longer had the same bluish tint, and the cerebral macula was less developed, and lasted a shorter time. From that time the improvement increased every day, markedly and continuously, and all the brain-symptoms disappeared soon, and pain was no longer complained of in the joints. As the appetite had returned, nourishment could be given. The girl was fairly conva- lescent, although her face still wore a singular expression; and although she had no choreic convulsions, her voluntary movements were still slightly uncertain. The cure was afterwards complete. In this case, gentlemen, St. Vitus's dance opened the scene; acute articu- lar rheumatism soon followed, preceded by cardiac symptoms, and then there supervened a grave complication, cerebral rheumatism. Rheumatism attacks children more frequently than is believed. Independently of the causes which produce it in adults, and to which children are equally liable, there is one cause to which they are more exposed than others, namely, scarlatina. When I come to speak of this exanthematous fever, I shall dwell fully on the coincidence of rheumatism and scarlatina; and I will tell you that it is pretty common (less so in children, however, than in adults, in whom this occurs in one-third of the cases) to see rheumatic affections set in during the acute stage of the eruptive fever; but as the rheumatism does not give rise to the general symptoms which Usually char- acterize it, as the patients complain little of it, and as it is most frequently confined to three or four joints (chiefly the wrists), it is often overlooked. Yet by carefully questioning the patients, by examining their joints with attention, and slightly compressing them, pain is found to exist in the joints from the third to the eighth day of the disease, sometimes later. Thus is explained the production of endocarditis and pericarditis, complications which manifest themselves when scarlatina is declining, pericarditis some- what more rarely than endocarditis. Deep emotion, from any cause, and most particularly fright, is a determin- ing cause of St. Vitus's dance. The young girl, 16 years old, who lay in bed 30, St. Bernard Ward, afforded an instance of this. Her previous health had always been good; she had never had rheumatic pains (and careful auscultation detected no sign of cardiac disease), and her complaint dated a fortnight back. A man caught hold of her one evening as she was going downstairs without a light, and she was so frightened that she had a nervous fit, and from that moment became affected with St. Vitus's dance. vol. i.-53 834 ON CHOREA. The disease was developed to a pretty high degree, and her case could be regarded as typical. , Several among you may recollect another girl, aged 17, who was sent into my ward by Professor Jobert, in December, 1860. She had an artificial anus in the umbilical region, which had rendered a surgical operation necessary. She had always been very nervous, and had a strange temper; and she wras so alarmed by the operation, that she was immediately seized with St. Vitus's dance, which was very grave, was attended with delirium, and got well by slow degrees also. The invasion of St. Vitus's dance is rarely sudden as it was in these two instances; in the immense majority of cases there are premonitory phe- nomena, which often escape notice, and thus induce the belief that the choreic movements developed themselves at once. These prodromata consist in impairment of the intellectual faculties. The child's temper changes; the joyousness habitual to its age is replaced by unusual sadness.and morosity, and he becomes capricious and agitated; he sheds tears copiously for the least thing; he is irritable; his natural timidity grows worse; he seeks solitude, and keeps away from his play- fellows. He becomes at the same time incapable of fixing his attention long; his aptitude for work diminishes; his memory is less retentive; and this enfeeblement of the intellect, which does not escape the attention of mothers (who, however, are always ready to exaggerate their children's qualities), increases still more in proportion as the disease progresses. I will presently revert to this important point. Generally, also, the patient complains of malaise, of headache, of vague pains in the limbs, and of precordial anxiety. The digestive functions lose their accustomed regularity; the appetite diminishes, digestion becomes more difficult, and there is constipation. The convulsive agitation is already announced by a wish to move constantly from place to place, and by uneasiness in the limbs; this agitation becomes more and more marked, and, lastly, the choreic convulsions manifest themselves. The symptoms of the confirmed disease show themselves sometimes in the upper, at other times in the lower extremities, and at others again in both at the same time. In some cases the face gets distorted first, but more frequently the upper limbs are the first to be affected, and it is of very rare occurrence indeed that the disease is general from the outset. As a rule, I repeat, chorea begins in one side and attacks the other side by degrees, involving the trunk and face also. In some very rare cases it is localized during the whole course of the disease, and we had in St. Bernard Ward an instance of this hemichorea. The right side was affected in that case, while most commonly unilateral chorea is on the left side. Even when general, chorea always presents something of a unilateral character- that is, the convulsive movements are more marked on one side than on the other, more particularly on the left. This may take place alternately also; for instance, the agitation may cease on the side which was most affected, and may become more violent on the other. Chorea which is partial at the beginning may remain so throughout, or after becoming general it may afterwards affect a few muscles only. Such cases are rare, however, and a great many of those which have been re- ported as such were not instances of St. Vitus's dance, but of tic, a species of chorea which should not be mistaken for it. If, at the outset, the symptoms which characterize this complaint are sufficiently slight not to attract the attention of the child's friends, and if they then consist merely in a want of precision of the voluntary movements, or in a sort of carphology, or in some more or less transient contortions of ON CHOREA. 835 the trunk and face; when the disease is fully developed, it can no longer be mistaken, and the most minute description cannot give an accurate idea of its strange and varied aspect. One is struck at first sight with the singularity, the uncertainty, and irregularity of the child's movements. He cannot remain a single moment at rest. He has a difficulty in remaining in the standing posture, for his legs bend under him, and then straighten themselves in an instant; his gait is peculiar, and he runs rather than walks. If he tries to take a step forward, he raises his foot higher than he desires, thrusts it right and left; and scarcely has this foot touched the ground again, than the other gets off at once and moves in a similar manner. His walk consists in constant leaping-in a sort of ill-cadenced dance, which assumes a more grotesque character, painful to witness, from the irregular movements of the upper limbs, the contortions of the trunk and head, which, according to Dr. Rufz's comparison, make the poor choreic patient resemble one of those puppets that are moved by strings. When the symptoms are very severe, the stand- ing posture and progression are perfectly impossible, and the patient is compelled to remain in bed under pain of falling down without being able to get up again. The upper limbs move likewise in different directions. They pass, with excessive rapidity, from a state of flexion into one of extension, from prona- tion into supination, and these various movements succeed one another without regularity. The patient succeeds in reaching a determined spot with his hand only after many efforts. If he tries, for instance, to carry it to his head, he raises his arm up, after many false moves, striking his face and forehead while doing so, and he is unable to retain that position long. When he tries to take hold of any object presented to him, he thrusts his hand forward as if his arm moved by means of a spring, then withdraws it with the same suddenness, without reaching his aim or going beyond it, and attaining it at last after numerous attempts; even when he gets at what he desires, it often is by upsetting it, and throwing it away from him. After seizing it he is on the point of dropping it suddenly; and when he has got hold of it at last, if it be a glass, for instance, and he tries to drink, he only succeeds with great difficulty; and before he does so, as Sydenham says, he makes a thousand and one contortions, moves his glass right and left, until, on its meeting his lips by chance, he gulps down the liquid; or, again, he holds the glass between his teeth, and lets it go only after empty- ing it. You may conceive, gentlemen, how difficult it is to nourish a patient in such cases, and why they have to be fed by others. The face wears a singularly imbecile look from the convulsions of its muscles, which give rise to grimaces of the most varied kind. The eye- brows, the skin of the forehead, the alee nasi contract and relax; while the eyelids are alternately raised and lowered, the lips pulled in various di- rections, the mouth opens and closes unceasingly, and the eyes roll con- vulsively in the orbit. As the muscles of the tongue are involved as well as the rest, speech is often hesitating, or the patient actually stammers, and can be understood with difficulty. Articulation is all the more embarrassed that the muscles of the larynx are themselves involved in some cases, and the sound of the voice being then altered, the patient utters a kind of bark. Strange sounds are occasionally produced through the voice coming out in inspiration instead of expiration. While the patient expires in the act of speaking, the inspiratory muscles suddenly contract convulsively, and cause the air to rush into the larynx; so that, from this kind of antagonism 836 ON CHOREA. between the mind that wills the speech and the inspiratory muscles, the voice undergoes a strange alteration. Lastly, the pharynx and other muscles of organic life may be affected; deglutition is then impaired, while, owing to the relaxation of the sphincters of the rectum and bladder, the urine and faeces are passed involuntarily. Such cases, however, are somewhat rare. Choreic convulsions, therefore, attack the muscles of the life of relation almost exclusively; and although the movements are involuntary, like all convulsions, the will still possesses a certain influence over them. The want of co-ordination seems to result from the fact that some of the contractions are involuntary, and others voluntary, but the latter are not in sufficient number to neutralize the former. I will explain myself. When the ■will commands freely-as, for instance, when it orders the arm to rise, or the leg to move forwards, the muscles which are charged with the execution of these movements do so with perfect regularity; they act with co-ordination, and in a perfectly harmonious order. Now, while this harmony persists still in hysterical chorea, and in the various kinds of trembling, in which the will is incapable of preventing the convulsions and yet commands combined movements, it does not obtain in St. Vitus's dance. In this complaint, on the contrary, it seems that the will is powerful enough to call the muscles into action, but is unable to direct or moderate them by means of the antagonistic muscles when the impulse has once been given; it seems that, instead of obeying then a single will, each muscle contracts at its own pleasure, or obeys different wills. This is an important fact, which is observed in St. Vitus's dance, and sometimes also in locomotor ataxy, as I have already told you. There is another phenomenon which is likewise special to this kind of chorea, namely, paralysis, which is almost always present. The limbs which are most affected with choreic movements are the seat of the paralysis; the arm, for instance, which is the most convulsed, is the one also in which muscular strength is most diminished. The child often complains that this arm is heavier than the other. The leg which is most convulsed is also the one which bears the weight of the body least, and which is dragged the most when the child walks. This coexistence of a greater degree of con- vulsive agitation and of a diminution of muscular strength, is all the more inexplicable that the paralysis is as mobile as the choreic affection with which it is connected. Thus when the chorea is more marked in one half of the body, the paralysis is also marked on that side; but if the convul- sions become more violent on the opposite side, that side will in its turn be paralyzed. This paralysis disappears almost always simultaneously with the chorea, but it may in some cases persist after it, and be complicated with atrophy of the paralyzed muscles, constituting then a more or less durable infirmity. In some still rarer instances, paralysis (I do not mean a mere diminution of muscular strength, but true paralysis) precedes the manifestation of con- vulsive phenomena. A girl, 18 years old, was brought to Paris by her mother, who was alarmed at seeing her seized with right hemiplegia. Professor Andral and I were asked to see her, and we made out that, besides a marked diminu- tion of muscular strength, there was also a very appreciable diminution of cutaneous sensibility on the right side. On carefully examining the pa- tient, however, we noticed that her right foot was constantly adducted and abducted in turn, that her hand was also perpetually agitated, her fingers bending and then straightening themselves out. Moreover, the patient kept her head inclined on her chest, and her face wore a singular expres- ON CHOREA. 837 sion of sadness and of fear. We immediately thought of St. Vitus's dance, and asked the mother whether these movements had existed for a long time, but they had not yet attracted her notice. The characteristic symp- toms which soon afterwards manifested themselves proved the accuracy of our diagnosis. The diminution of sensibility which we found in this case exists in most instances, for disorders of sensibility are nearly constant in St. Vitus's dance. I have already spoken to you of the vague pains which the patient feels in his limbs, and which, after announcing the invasion of the disease, per- sist when it is fully developed. To them are then superadded a sensation of formication, of tingling, and more or less marked anaesthesia, which is always greater on the most convulsed side. You saw me prick and pinch the young woman in bed 31a, in St. Bernard Ward, and thus recognize this perversion of tactile sensibility. This patient also told us that she could not see very well with her right eye, and that this weakness of sight had set in since the first attack of the same complaint, which she had had a year before, and that it had never improved. This impairment of sight, which is probably due to paralysis of the retina, has been pointed out by several authors; Dr. G. See records an instance of it which fell under his own observation, but he justly adds that this accident is excessively rare. The convulsions, and the motor and sensory paralysis, are not the only indications of the perturbation of the nervous system. With very rare exceptions there is in every case a more or less marked impairment of the intellectual faculties. This consists in a deeper modification than the timidity and the change in the moral disposition of the patient which I have men- tioned already. I do not mean, gentlemen, that a person who is afflicted with St. Vitus's dance becomes demented or an imbecile; but although he looks stupid, owing to the singular mobility of his features, and the im- pediment in his speech (which circumstance may certainly mislead, and induce the belief that the intellectual impairment is greater than it really is), yet it is unquestionable that his intellect is below par. If he happens to be at school, the change which has taken place in him is found out by his losing his place in the class. In some exceptional cases there have been signs of real insanity, and you saw an instance of this in the young woman of whom I have already spoken, and who became choreic after an operation performed by M. Jobert. This intellectual disturbance is as transitory as the disease itself. There are instances on record, however (rare though they be), of children who never again showed the same degree of intelligence as before they became affected with St. Vitus's dance; and cases have been even related in which deep changes had been left behind-namely, a certain degree of hebetude, and even of mental alienation. It more frequently happens that nervous excitability and an exaggerated sensitiveness persist in some cases. These disorders of innervation manifest themselves also in the organic functions, and to them are due the precordial anxiety and the palpitations of the heart complained of by the patient. The latter are accompanied by a soft blowing murmur, which is heard over the base of the heart, along the vessels of the neck. It is an anaemic murmur, which should not be con- founded with the rough bruit that characterizes rheumatic endocarditis, and it is owing to chlorosis, which often complicates if it does not precede chorea, and may be regarded as an effect of the influence of this disease on nutri- tion. The chlorosis is, besides, characterized by the discoloration of the integuments, by vertigo, headache, neuralgic pain, singing in the ears- 838 ON CHOREA. sometimes by swelling of the face, and in girls by dysmcnorrhoea and even amenorrhoea. The disorders of the digestive functions, which showed themselves from the beginning, either continue, or reappear and produce gastralgia. There comes a time when the appetite, at first capricious, is lost entirely, when digestion is painful, and there is actual overloading of the stomach. Con- stipation is also habitually present, as Sydenham pointed out long ago. Emotion increases the violence of the convulsions, and you should bear this in mind, lest you be mistaken as to the real gravity of a case, on seeing for the first time a patient who is not used to you. It is a remarkable circumstance, which happens in every case, that these convulsive movements, however disorderly, violent, and persistent they may be when the patient is awake, cease completely during sleep, and the patient looks as quiet as in health. In grave cases, however, he is restless, his sleep is of short duration only, and interrupted by bad dreams. In still more severe cases, the excessive agitation of the nervous system produces insomnia, which in its turn, acting as a cause of greater excitability, gives the unfortunate patient no rest at all. Brain-symptoms then set in-delir- ium, coma-and the patient gets into a state of exhaustion which tends to a fatal termination. When I come to speak of treatment, I shall tell you how to combat this dangerous complication, which, if not opposed in time, becomes so severe as to be soon beyond remedy ; and I shall tell you also that, although they be of real and unquestionable utility, these measures are no longer useful, and should be replaced by others as soon as the dis- ease resumes its regular course. Although St. Vitus's dance usually terminates favorably, and gets well after having lasted from one to several months, it may not only leave behind it, as I have told you, excessive nervous irritability, partial paralysis, and intellectual debility, but it may also cause death. Although such cases are rare, they are but too frequent still; and I told you of two instances-one that of a young woman in St. Bernard Ward, and the other of a girl at- tended by Dr. Legroux and myself. I have myself met with five or six cases of the kind in the course of my practice, and M. Moynier has related several similar instances of'the kind in his thesis. Death may take place from the extreme agitation; it may be due to neru vous exhaustion, or to cerebral rheumatism (as in cases which I shall relate to you), or it may be the result of no less formidable accidents. The patient may die of a fever similar to that which kills persons who have been burnt over a large surface, and the analogy is the more striking that this fever arises from more or less numerous and extensive wounds, which are pro- duced in the following manner. I told you that choreic patients wTere sometimes unable to stand, and were compelled to remain in bed. Their agitation is then so excessive that they are kept in bed with the greatest difficulty. Their movements are so disorderly and violent that they knock themselves against the wood or ironwork of the bedstead, bruise themselves severely; and these bruises, getting inflamed, become the starting-points of purulent infiltrations and of phlegmonous erysipelas. Or, again, they rub off their skin, which they literally wear out by constantly rubbing against the bedclothes, which they tear to pieces. Horrible wounds are thus produced, which, deepening by degrees, reach the bony prominences of the heels, the malleoli, elbows, spine, and scapulae. You may conceive the consequences which must follow the pain and abundant suppuration to which these wounds give rise. Such wounds are the more easily produced that the same thing happens in St. Vitus's dance as in grave fevers-in all diseases, in fact, which ON CHOREA. 839 deeply affect the nervous system, and in which there is a marked tendency to suppuration and ulceration. The.fol lowing case, which was communicated to me by a country prac- titioner, is an important one, as bearing on this point: A young girl, whose mother was healthy, but whose father had been subject to eczematous eruptions, and who was of delicate health herself, and had had, in the preceding year, eczema of the head, neck, and shoulder, became choreic. The disease grew so violent in a few days that she was unable to feed herself. Strychnine was given, in gradually increasing doses (up to 1-1 grain) in the course of the twenty-four hours; it did not produce tetanic rigidity, and quieted the symptoms markedly, so that the patient was soon able to drink by herself, with scarcely any difficulty. The tip of the right thumb, however, became affected with a whitlow, which got well rapidly ; but two days after the wound had healed, although the convulsions had notably improved, the child was seized with high fever and diarrhoea. Diffuse phlegmonous inflammation of the hand soon showed itself, which in less than twenty-four hours involved the back of the wrist and forearm, so that several incisions had to be made. From the outset the greatest precautions had been taken, in order to prevent the excoria- tions which the agitation made one dread. The patient was placed on a mattress laid on the floor, and constant watch was kept over her. Later, when the convulsions became more violent, her limbs were wrapped in small cushions, and then a strait-jacket put on. The phlpgmonous in- flammation of the upper limb seemed to be proceeding towards a favorable termination; the suppuration was less ; the walls of the suppurating cavity had a tendency to adhere together ; the fever had ceased, and the convul- sive movements continued to improve, when fever and diarrhoea returned with greater severity. Phlegmonous inflammation attacked the lower limb also, and within two days it affected the right leg and thigh, and this time it resisted all treatment. Unhealthy pus was secreted, the skin became loose over an extensive surface, the wound ulcerated, the soft parts were destroyed, and the tendons exposed. Numbers of bullfe, filled with a cloudy and purulent serosity, developed themselves on the neck, trunk, and limbs, especially on the arms-some of the diameter of a lentjl, and others of a larger size; ulcers formed on the lips and tongue and in the pharynx even. The fever became more violent, typhoid symptoms set in, and the patient died about three weeks after the manifestation of the first phlegmonous in- flammation. In this case, as the practitioner who attended it remarked, death was the consequence of the nervous exhaustion, brought on by excessive jacti- tation and exaggerated by sleeplessness; for the poor child had scarcely four hours' sleep, and even then of interrupted sleep, in the course of the twenty-four hours. The exhaustion was increased by the malnutrition of the patient, who could not feed herself, and, lastly, by the abundant suppu- ration of the phlegmonous erysipelas from which she suffered, and the starting-point of which, like that of the bull®, was the adynamia which was consequent on this nervous exhaustion. Death comes on, sometimes, as a result of cardiac rheumatic complica- tions, as in the following case, which was in one of my wards : A young woman, twenty-four years of age, was admitted into St. Bernard Ward on February 3, 1861. She told us, and her mother confirmed her statement, that on January 1, she had had, with her sister-in-law and her husband, a rather sharp quarrel, which had excited her considerably; soon after this, it was noticed that she was more irritable than usual. On January 15 she had not perfect command over the movements of her right 840 ON CHOREA. hand, and had some difficulty in sewing and ironing. To this disorder of motility, which rapidly increased in the right arm, there was superadded a certain degree of agitation when she walked. She still continued, how- ever, to attend to her household, and to nurse her last child, who was five months old. In the last days of January the movements of the right side of the body were more disorderly, and became notably more so every day. On her admission her right hand and arm were most affected, and were constantly moved in jerks ; her gait was unsteady, and she rested instinc- tively against the wall or against her bed when she stood up. Sensibility was found normal wherever it was tested, and the patient's mind was clear; the choreic movements of the muscles of her face, and especially of her lips imparted to her physiognomy a rather strange look. Her manner of speaking was markedly hurried, and her thoughts, although very clear, were extremely versatile. Thus, when it was proposed to take away her child, who ran the risk of being dropped from her arms, she began to cry ; then comforted herself, asking that her friends should have the child, and a moment after requesting that he should be left with her. For several months past she had only slept or even dozed for four or five hours every night, complaining of numbness in the limbs, which disappeared only when she shifted herself, or when she got up and walked about. She had never had rheumatic pain, and no blowing murmur was heard over the heart. Her previous health had been good until January 1. Her muscular strength, yhen tested with the dynamometer, gave twelve pounds for the right hand, and nine pounds for the left. For the first two days after her admission into the Hotel-Dieu, she took two spoonfuls of the syrupus strychnise. As her agitation persisted, I then gave her syrup of opium, repeated every hour, in order to procure sleep ; and although the dose of extract of opium amounted on the first day to 11 grains, she only had four hours' uninterrupted sleep. On the following days, the quantity of opium was gradually increased, but without benefit. The agitation was still extreme on February 9; the patient kept shrieking, and rolling through the ward in search of fresh air; her mind was not af- fected, for she gave clear answers to questions put to her. But her agita- tion, the curt and jerked manner in which she spoke, her singular aspect, the constant movements of the muscles of her face, and continued want of sleep for three days, indicated great cerebral excitability. The quantity of opium was again increased on February 9; laudanum was added to the syrup, so that from 9 a.m. to 6 p.m. she took every hour 2 grains of extract of opium ; this dose was slightly diminished in the evening. She fell asleep at 12 p.m., after having thus taken from 15 to 17 grains of opium. The next morning her breathing was calm, her pulse was very regular, and had a certain degree of strength (120 to 130) ; her pupils were contracted, and she was in a deep sleep, from which I did not attempt to rouse her. About half past twelve, how7ever, her respiration suddenly became embar- rassed, and there was some tracheal rhonchus ; the breathing suddenly be- came inappreciable, and the patient, who looked as if asleep, died without agony and without fresh convulsions. A post-mortem examination was made on Tuesday, February 21, forty- four hours after death. There was no notable change in the brain and spinal cord. There was merely slight injection of the cerebral meninges, without a large amount of serosity in the ventricles. The cortical and central white and gray matter were of normal color and consistency. The pia-mater could be stripped off' without lacerating the cerebral substance, and there were no opaline spots in the interlobar fissures. The lungs pre- sented only a few cicatrices at the apex, and were not engorged. The heart ON CHOREA. 841 was in its normal position, and of normal size and color. The right cham- ber of the organ and the pulmonary artery contained no fibrinous clots nor blood-concretions, and the orifices were free and healthy. The endocardium was of pinker hue than normal in the right and left chambers. The aortic orifice was free, and the sigmoid valves healthy. The mitral orifice was of normal dimensions, but the mitral valve was covered, on its free edge and on its auricular surface, with small polypoid concretions, of pink and yellowish color, agglomerated, mulberry-like, very adherent, semi-transparent, and resisting pressure. Under the microscope (600 diam. Nachet) they were seen to consist of amorphous granulations and rudimentary fibrillae of con- nective tissue. There was valvular endocarditis, and yet there had been no blowing murmur during life, for we had only heard a dry valvular click. The abdominal organs presented nothing worth noting. There were nu- merous ecchymoses on the arms and legs, and incipient sloughing over the sacrum. As in the case of other neuroses, pathological anatomy teaches us scarcely anything as to the material alterations of the nervous centres in St. Vitus's dance. If you consult various authors, you will find contradictory facts and opinions. One looks upon inflammation or induration of the tubercula quadrigemina as the characteristic lesion of the disease; another regards as such induration or hypertrophy of the brain or of the spinal cord, or a more or less extensive softening of the cerebro-spinal centres; a third be- lieves in calcareous concretions of the brain, a fourth in cysts of the pineal gland, or osteoids of the vertebral canal, and I know not what else. But does not this very diversity of the lesions found after death prove that there is no relation between them and the dynamic phenomena, even if it had not been ascertained that in most cases no appreciable anatomical change can be detected in the nerve-centres? For my own part, in the rare in- stances in which I have examined the bodies of individuals who had died of St. Vitus's dance, after presenting the most violent symptoms of the disease, I never met with any lesion, I do not mean which could account for death (for in all diseases whatever, in which there is an evident relation between certain symptoms and certain organic lesions, the latter are far from al- ways accounting for the cessation of life, especially in cerebral affections), but which seemed to me to be in accordance with the convulsive phenom- ena of chorea. Because tubercles were found in the brain in some instances, no one can infer that this pathological condition is a characteristic lesion of St. Vitus's dance, and even in such cases it may be questioned whether there was any correlation between the tuberculization of the brain and the chorea. I do not, of course, allude to cases in which there were merely choreiform symp- toms, for such are no more instances of chorea than epileptiform seizures are of true epilepsy, and the symptoms are evidently dependent, more or less directly, on the appreciable organic alteration. In cases of genuine chorea, the question arises, whether there was not merely a coincidence between this neurosis and the organic lesion in the brain, and whether they were not both manifestations of a diathesis and nothing more? This view of the question is very plausible, or admits at the very least of discussion, when it is remembered that St. Vitus's dance may show itself in phthisical individuals, in whose nervous centres no tubercular deposit is found after death, although such deposit may be seen in other parts-in the peri- toneum, for instance, as in a case of Dr. Rufz, or in the lungs, as in a pa- tient under my care at the Necker Hospital. It is not, therefore, this or that lesion which caused the development of the convulsive affection ; but it is the diathesis itself, which not only revealed itself during life by special 842 ON CHOREA. symptoms, and after death by peculiar anatomical characters, but which expressed itself also by the production of St. Vitus's dance, as it does in other cases by the development of other neuroses. As to the rheumatic organic lesions of the heart and of serous membranes, they are a material proof of the relations which exist between rheumatism and St. Vitus's dance, but they have never been regarded as characterizing the disease. I wish now to call your attention to the influence which Intercurrent Febrile Diseases possess on St. Vitus's dance, and, vice versa, the latter on the former. Dr. G. See is the one who has studied this point the most. " While chorea but slightly modifies intercurrent diseases, the latter, febrile affec- tions in particular, have unquestionably an influence on the course of ner- vous phenomena in general, which has been clearly indicated in the works of the ancients. ' It is better,' said Hippocrates, ' that fever should set in subsequently to spasms than spasms after fever.' In another passage he speaks in clearer terms, saying 'that spasms may be arrested by acute fever '-an axiom which is fertile in applications, but which has been re- jected by many, because it implies important restrictions, which have not been taken into account, and have therefore raised doubts as to the truth of the statement. For if there be instances of chorea on record which was arrested by an exanthematous fever, and afterwards recurred for a time, only disappearing at last rapidly with or without treatment, thus conclusively showing the influence of the fever on the course of the chorea, there are other cases also which clearly indicate that the axiom of Hippocrates may be completely at fault. Thus Dr. Rufz rejects it, and relates two cases of chorea complicated with measles, one of which continued until death with- out becoming modified. "The only way to interpret these difficulties, and to conciliate opinions that are so opposed to each other, is to appeal to clinical observation, and submit the facts to a rigorous analysis. Now, of 128 cases which we col- lected, and in 70 of which febrile complications existed, rheumatic fever was present 25 times, and exanthematous fevers 17 times-namely, scarla- tina, 10 times ; measles, 3 times ; idiopathic, ephemeral, or catarrhal fevers, 12 times; and inflammations, 16 times (pneumonia, 7, angina, 3, phleg- monous inflammation, 4 times, and diphtheria twice). " These various diseases, which have but one symptom, fever, in common, exert a similar influence on the nervous phenomena. When these are on the point of disappearing, they are suddenly arrested by the fever, but this is exceptional only. When they are not declining, the fever first produces a general excitation, attended with evident exasperation of the choreic move- ments, which latter continue as long as the premonitory and invasion stages, and the period of increase of the disease last (from twenty-four to thirty-six hours in the case of ephemeral fevers, and from two to seven days in continued fevers and in inflammations) ; then, as soon as the fever has reached its point of maximum intensity, the choreic jactitation begins to calm down; and from the time when the reaction ceases, although the pulse is more fre- quent, and the heat of the skin still greater than in health, the spasmodic movements diminish, and lastly disappear for good-yielding to the efforts of nature alone, and the more easily that the neurosis has been of longer duration. Lastly, in a case of chorea which has just set in, or which is on the increase, the only favorable change is that which takes place in the in- terval of time which elapses from the invasion of the fever; hence, if the fever lasts for a short period only, and does not allow time for the improve- ment of the nervous symptoms, the latter persist until the patient's strength is exhausted; and when his general condition is such that his life is en- ON CHOREA. 843 dangered, the gesticulations recur until death. In nine cases which ended fatally, the muscular agitation continued in this manner until death, run- ning fatally, as it were, a parallel course to the phases of the intercurrent disease. All these circumstances seem formally to contradict the principle enunciated by Hippocrates; for although it expresses a real and certain truth, the statement is only accurate if the precise moment when the crisis takes place be taken into account. The disappearance of the nervous phe- nomena does not occur at the outset of the fever, but generally after the remission of the febrile symptoms, and on the express condition that the nervous state be on the decline; so that whenever fever is lighted up in a patient who has been suffering from chorea for five or six weeks previously, the convulsive movements will cease : spasmos febris accedens solvit. Most of these remarks are applicable to the various kinds of chorea." I told you, gentlemen, that after lasting a variable time, St. Vitus's dance in most cases got well; the improvement is nearly uniform in its course, the convulsions disappearing in the lower limbs before they do so in the upper extremities. Their violence goes on decreasing, and there comes a time when they only manifest themselves when the movement which is performed requires a certain degree of energy or a good deal of precision. The face, however, still retains for some time a grinning expression, and the intellect remains weak. At last all these symptoms disappear, and the patient recovers his normal condition. It is not uncommon, however, that the cure is temporary only; after a variable period of time, a few weeks perhaps, the agitation returns, and there is a relapse. In other cases, several months, one, two, or three years, elapse before a recurrence of the disease takes place. It is worthy of notice, that the duration of the complaint in relapses and recurrences is generally shorter than in the first attack. This law of de- crease is far from being absolute, however, for the reverse obtains in some cases. Thus Dr. Moynier saw a child, ten years old, whose first attack of chorea lasted two months, while a second attack lasted two months and a half, and a third and last three months. In another case the first attack lasted two months, the second three, and the third five months. But as the law of decrease applies to the generality of cases, you should be aware of it, and you should take it into account in order to appreciate the value of the treatment which has been had recourse to. From not paying sufficient at- tention to the natural course of the disease, and from not taking into con- sideration that after having gone through its different stages, and lasted a determinate period of time, St. Vitus's dance generally got well spontane- ously, cures which were entirely due to nature have been ascribed either to methods of treatment based on more or less erroneous theories, or to em- pirical remedies. Although this is the case in a great many and perhaps in most cases, in some, however, medical interference may be of use, by di- minishing the violence of the symptoms, and shortening a little (sometimes very markedly) their duration. It may be especially of use against certain complications, which, if left to themselves, may lead to the most fatal con- sequences. Now, gentlemen, what are the therapeutical measures of which we can dispose in the treatment of St. Vitus's dance ? I will spare you the tedious enumeration of a great many remedies which have been recommended, based on certain theoretical views which are per- fectly erroneous; nor will I say anything of those pretended specifics which have been invented by superstition, or by coarse empiricism, and which are nowadays justly forgotten. I will only speak of those methods of treatment the efficacy of which is recognized, which slightly disturb the natural phe- 844 ON CHOREA. nomena of the disease, and make the patient run the least amount of risks, and which have been adopted by the generality of good practitioners. The water-cure, vaunted first by Dumangin, formerly physician to the Charite Hospital, by Bayle, and afterwards by Jadelot, of the Children's Hospital, consists in the administration of baths, or the use of cold lotions, with water of 10° or 15° Cent. The baths or the lotions are repeated two or three times a day, for one or two minutes each time; and the child is quickly wiped and dressed, and should immediately afterwards take as much exercise as possible. This treatment acts both through the sedative and tonic properties of cold, and through the momentary perturbation of the nervous system which it occasions. It moderates the intensity of the disease, even though it does not arrest it, or sensibly shorten its duration; and from its favorable influence on the whole system, it places the patient in a good condition for going through the attack. River and sea-bathing are other forms of the same method of treatment, and I recollect seeing, at an establishment of mineral baths, an arrangement intended to imitate what is known under the name of wave-bathing. The patient was placed on a kind of swing, so arranged that when it oscillated he went very rapidly through the most superficial layer of the water in the tank over which he was balanced. Cold baths have, however, unquestionable disadvantages. Children, on the one hand, take them with a certain reluctance, and on the other hand, even when they are administered with the greatest precautions, they may bring on rheumatism, which was only threatening, or intensify it if it be already present; in the latter case, therefore, they should be abstained from. On this account, cold baths were replaced at the Children's Hospital by baths at from 15° to 18° Cent. (59° to 65° Fahr.), and I have myself ad- vised that the child should be merely dipped two or three times into water at first of 24° Cent, (about 75° Fahr.), but the temperature of which was to be gradually lowered every day. Baudelocque was the first to propose sulphur-baths, and to lay down rules for their administration and their indications; their efficacy is sufficiently marked to make most trustworthy practitioners (my colleague, Dr. Blache, among others) adopt them as their chief remedial measure. They should be prepared with from half an ounce to an ounce of sulphuret of potassium dissolved in 100 litres of water, at a temperature of from 30° to 31° Cent, (about 86° Fahr.), and should be taken for an hour at the most. It is essential that they should be repeated with great regularity every day. In cases of threatening rheumatism these baths are contraindicated. Besides, gentlemen, the great medical law, on which I every day insist so much (for it finds its application every moment)-namely, the influence of medical constitutions on the results of treatment-also applies to chorea. Thus, Baudelocque and his colleague, M. Bouneau, found themselves com- pelled, in a period of from eight to ten years, to vary their treatment of chorea: at first the disease was quickly cured by cold water, but a few years later sulphur-baths had to be administered ; while these latter again proved of no service after a time, and had to be replaced by preparations of iron. Among the various methods of treatment of chorea, gymnastic exercise certainly holds a pretty important rank; and Dr. Blache has of late made an interesting communication on this subject to the Academy of Medicine,* * " Memoires de 1'Academie de Medecine " (Paris, 1855), t. xix, p. 598. See also a learned report by M. Bouvier (" Bulletin de 1'Academie de Medecine," t. xx, p. 882). ON CHOREA. 845 in which he has given the results of his long experience. The idea is not novel, although it has been recently brought forward again; for Dr. Louvet- Lamarre (of St. Germain-en-Laye) published a case,* in 1827, tending to show the utility of gymnastic execises. The kind of exercise which he par- ticularly recommended was that of skipping with the rope. I have many a time heard Recamier speak in terms of praise of the good results which he had obtained from what he called prescribed and regulated gymnastic exercise, and which consisted in performing movements in measured time. He thus told choreic children to follow drummers when beating to quarters, and recommended their friends to make them beat time several times in the day. I have often availed myself of this idea of Recamier, and have advised choreic individuals to execute rhythmical movements, guided themselves by a metronome, or by the pendulum of one of those village-clocks called cuckoos, keeping time to their oscillation. In the beginning partial movements are executed as directed, then combined movements, at first quickly (for they are more easily performed thus), and then more slowly. I have by this means succeeded in modifying not the symptoms of St. Vitus's dance alone, but of other kinds of chorea, also and in particular of the forms of tic, which I shall speak of presently. It would seem as if, in this method of treatment, a strange will replaced, after a time, the patient's will, which was unable to co-ordinate the move- ments which itself commanded. The principle according to which the gymnasiarch deals with the indi- viduals who are intrusted to his care, is exactly similar to the one which I have just described. He makes them go through certain movements, which he first performs himself before them ; and in order to insure their being done harmoniously, he makes them repeat with him cadenced songs. He begins with simple movements, such as the acts of stretching out and bending the arms, flexing and extending the knees, and striking the ground with the foot in cadence; and when the children succeed in executing these movements with regularity, he tries to make them walk in step, slowly or quickly, and next he makes them run. Lastly he makes them swing or raise themselves by their arms, going by that means through manoeuvres which are gradually more complicated. These exercises are repeated every day, anol are not kept up for more than half an hour, so as to be within fatigue. There are certainly great difficulties to overcome in the beginning, but in a short time, and from the first attempts, a certain regularity of the movements is obtained for a few moments, and this improvement becomes more and more marked. But regulated gymnastic exercise cannot always be managed, and may then be replaced by movements regulated by means of a metronome or of a pendulum, by exercises such as dancing, skipping with a rope, &c., although the latter are not followed by the same beneficial results. It is especially towards the close of the disease that such results are obtained, so that gym- nastic exercises are only accessory in the treatment of St. Vitus's dance, and I have more faith, therefore, in the internal administration of remedies. Of these remedies, some act on the general condition of the system, which complicate the chorea, and influence it more or less. First among these are tonics and preparations of iron, .when the disease is due to chlorosis, which not only accompanies but often precedes it. On the same ground, again, arsenic has beCn prescribed, from its possess- ing, as you are aware, the property of causing general excitation, and espe- cially increased vigor of the lower extremities. Dr. Rayer, who has given * "Nouvelle bibliotheque medicale," t. xvii, p 408. 846 ON CHOREA. it in cases of old and obstinate chorea, which had resisted the usual methods of treatment, has thus been able to improve and even to cure them com- pletely. Yet, gentlemen, although other instances in which this treatment was successfully employed have been recorded by Thomas Martin (who first used arsenic), by Gregory, by Latter, and more recently by Babington, by Hughes, and by Begbie, this drug has been laid aside by these very men who were the first to advocate it, either on account of its difficult adminis- tration, and the prudence required, or because the success attending it was really questionable. Yet, let me add at once, arsenic is administered with greater facility than iodine, and especially than strychnine, of which I shall presently speak. Iodine and iodide of potassium have been likewise vaunted, and are indi- cated when the object is to modify a strumous diathesis and a predominating lymphatic temperament. Other modes of treatment act directly on the nervous system. One of these is pre-eminently a sedative plan, which is said to have been formerly used with benefit by Rasori, and without doubt by Laennec, in 1822, and which has been revived within the last few years, after having been for- gotten for a long time: I mean the treatment by tartar emetic in large doses. My learned confrere M. Bouley, in 1857, adopted this treatment with some modifications ; and about the same time my regretted colleague, Dr. Gillette, tried it at the Children's Hospital. The results of his trials were published in the following year (1858) by Dr. E. Bonfils, in an excellent thesis, which I advise you to read. After the modifications of this plan which Gillette suggested, and the good results which he obtained, it may be said that the use of tartar emetic in large doses became of very great importance in the treatment of chorea. Gillette advised that it should be administered according to the follow- ing rules, which Dr. Henri Roger followed rigorously, in the cases which he communicated to the Medical Society of Hospitals, and which were published in the "Union Medicale" for June and July, 1858. The whole treatment generally comprises several series, each of which is of three days, and is separated from the next by an interval of from three to five days. On the first day, tartar emetic is given in doses of from 4 to 5 grains in the twenty-four hours. This quantity is doubled on the second and trebled on the third day; after this the patient is allowed to rest for three or five days. If a second series be necessary, that is, if the chorea persist to the same degree, or if the convulsive movements have merely diminished in violence, tartar emetic is again administered for another period of three days, beginning with the same dose as on the first day of the first series, plus an additional grain. If, after another interval of rest of four or five days, the disease is not cured, or only incompletely so, the medicine is given for a third time, accord- ing to the same rules; that is, the dose given on the first day of the third series will be the same as that administered on the first day of the second series, plus an additional grain. So that if the dose given on the first day of the first series be 4 grains, that on the first day of the second series will be 5 grains, and on the first day of the third series 6 grains, and on the third day of the third series 18 grains. I had recourse to this plan, in the case of a patient under my care, in whom St. Vitus's dance was complicated with hysteria, but no improvement was obtained until after several weeks. Dr. Bonfils, who superintended the ON CHOREA. 847 treatment, did not look upon the case as a successful one, but it is impossi- ble to draw any conclusion from a single instance. A great many cases, however, have been published by Dr. Bonfils, which are not all of equal value, no doubt, but which yet seem to me worthy of drawing attention to the administration of tartar emetic, according to (fillette's method. It pretty frequently happens, according to the authors whom I have mentioned, that the chorea improves very markedly after a first series, and in some instances even, if the disease be only of medium intensity, an immediate cure is obtained. But they themselves acknowledge that two or three series in succession are required for a thorough and final cure. Now, if it be borne in mind that the successive series comprise a period of twenty-one days, that the duration of the disease from its commencement is also to be taken into account, as well as the possibility of recurrences, doubts will arise as to the efficacy of the remedy. By carefully reading and analyzing the cases published by Dr. Bonfils, it will be seen that the treatment was continued for a period of from fourteen to twenty-five days; that the first manifestation of the disease, when this point was noted, dated two and even three weeks back; lastly, that many of the cases were instances of recurrence of the complaint, which always lasts much less than in previous attacks. It might well be asked, then, what advantages tartar emetic has over cold affusions, sulphur-baths, and strychnine (of which I shall presently speak), by which the disease may in general be cured; and why, therefore, a plan of treatment should be revived which has been already tried, and then laid aside, arid which is somewhat violent in its mode of action, especially in delicate individuals, as many choreic girls are ? Surely, gentlemen, I am, less than any one else, disposed to doubt the efficacy of the various remedies which are habitually used against chorea, and I admit that the treatment by tartar emetic is in many cases contra- indicated. But I must also remind you that although chorea yields, in general, to ordinary treatment, and still more to the influence of time, there are yet certain cases, unfortunately, in which the convulsive agita- tion is so great, that all known remedies are of no avail; and the physician sees unfortunate girls die a miserable death, with an excoriated and deeply ulcerated skin, the result of friction which no amount of restraint can pre- vent. Now, should tartar emetic in large doses be of use in such cases, after all other remedies have failed-(and a certain number of cases tend already to raise the hope that this powerful drug, both perturbing and sedative at the same time, is capable of mastering and in some sort crush- ing chorea which has resisted all treatment)-even if it should be exclu- sively restricted to such exceptional instances, therapeutics will be really indebted to Gillette for promising it another chance of success where it was formerly compelled to acknowledge its impotence. The treatment, how- ever, which has seemed most beneficial to me, and which I generally adopt, is that by strychnine. Lejeune had recommended nux vomica, and Niemann and Cazenave (of Bordeaux) had also, as a last resource, treated by it a case of chorea with complete success, when, in 1831, I myself administered it to a patient suf- fering from paralysis and chorea at the same time, less with the view of curing his chorea than with that of treating his paralysis. It was in 1841 only that I laid down distinct rules for treating chorea by this method, and carried on my experiments openly at the hospital. About the same time (without any of us being aware of what the others were doing) Dr. Fouilloux and Dr. Rougier (of Lyons) recommended the methodized administration of strychnine in St. Vitus's dance. While I 848 ON CHOREA. was taking notes of and publishing cases of chorea cured by mix vomica, Dr. Rougier published also the results of his researches; but instead of nux vomica, he recommended the use of strychnine. Since that time I have myself adopted strychnine, and the preparation which to me seems the most easily managed is the syrup of sulphate of strychnine (one grain of the salt to two ounces and a half of syrup) ; and I prefer the sulphate to strychnine itself, because the latter is very slightly soluble, whereas the former dissolves to any extent. Two ounces and a half of the syrup are equivalent to twenty teaspoonfuls, each of which, therefore, contains one-twentieth of a grain of the salt. Two teaspoonfuls are equal to a dessertspoonful, which, therefore, contains one-tenth of a grain of the salt; and a tablespoon will contain one-fifth of a grain of the sulphate of strychnine. You must remember that this syrup is not offi- cinal, and you must therefore be careful when you prescribe it. In spite of its bitterness, children do not show very great reluctance to take it. I now wish to direct your attention particularly to the mode of adminis- tering it. According to the age of the patient, give on the first day from two to three teaspoonfuls of the syrup, and see that they are taken at equal intervals of time during the day (morning, noon, and evening), so that you may watch the effect produced, in order not to go beyond a certain point. If the dose of three teaspoonfuls be well borne, it is continued for two days, and then increased by one teaspoonful; after another two days, the dose is again increased by another spoonful, and so on, until six teaspoon- fuls are taken in the course of the day-always at equal intervals of time. When this dose has been reached, a dessertspoonful is substituted for one of the teaspoonfuls ; and by attending to the same rules as before, as many as six dessertspoonfuls are administered, containing three-fifths of a grain of sulphate of strychnine. A tablespoonful is then substituted for one of the dessertspoonfuls, and by gradually increasing the dose, with the same prudence, and taking the essential precaution of giving the medicine at perfectly equal intervals of time in the course of the day, you may in the end administer to the child from three-fifths to four-fifths, and even one grain and one-fifth of sulphate of strychnine. In the case of adults the dose should be larger from the beginning-a dessertspoonful, for example; and it may be gradually increased to as much as two grains of the active principle. But bear well in mind this most important fact, gentlemen-that you should always begin with small doses, and watch their effects, and before increasing should continue them for a couple of days. The treatment should be carefully watched, because the drug must be given in sufficient doses to bring out its physiological effects ; and the patient's friends, or the persons about him, should be fore- warned of what is to happen. After a very few days have elapsed, and as soon as the first doses are increased, the patient complains, at certain periods of the day, twenty min- utes or half an hour after taking the medicine, of some stiffness of the jaws, of headache, of impairment of sight, of a little giddiness, and of slight rigidity of the muscles of the neck. He complains also that the hairy parts of his person and his scalp itch; the sensation next extends to the non- hairy parts, and in some cases an eruption of prurigo comes out. As the doses are increased the stiffness becomes general, and is most marked in the limbs that are the most convulsed (and these are also the most paral- yzed, as you know). Muscular jerks occur occasionally also at the same time, and oftentimes spasms and convulsions in hysterical persons. These starts happen in particular when the patient is taken by surprise, or when an order is given him before he has time to will, and they may be so vio- ON CHOREA. 849 lent that he is thrown down. I remember a young girl, 18 years old, who was under treatment for St. Vitus's dance, at the Necker Hospital, and who, on being unexpectedly addressed by one of the sisters, was seized with tetanic contractions of this kind, and thrown forwards as by a spring. These tetanic contractidns are painful, especially when the patient tries to resist them, and to remain standing ; they are instantly quieted, however, on the patient assuming a horizontal position. When these physiological effects show themselves the doses should not be increased, because strychnine, like all preparations of nux vomica, belongs to that class of remedies which, by virtue of a special therapeutic influence, and a very remarkable cumulative action, as it were, are apt to give rise to perfectly unforeseen accidents, even though the moderate doses in which they were administered had until then given rise to scarcely appreciable effects. If it be important that the physician should not be alarmed by the physi- ological phenomena which he must try to produce, and which, however uncomfortable they may be, are serious only when they are pushed too far (and this never happens if the syrup be properly administered), it is equally important that he should bear in mind that this drug is variously tolerated by different induviduals, and by the same individual at different times; so that, even by continuing the same doses, one cannot predict from the effects obtained on the previous day those which will be produced on the next. Thus, six spoonfuls of the syrup may not cause any appreciable physiological effect one day, while, on the next, violent spasms may come on immediately after the first spoonful, even when the same preparation is used, of known strength. I need not add, that when the administration of the first spoonful brings on spasms, the medicine should be stopped for the day. There being nothing to account for such results, I tried to make out whether meteorological conditions had any share in their production, but my inquiries led to no conclusions. This variability in the degree of power of the drug renders its adminis- tration a delicate matter, and demands the most scrupulous care; and on this account perhaps this method of treatment will not obtain the impor- tance which its unquestionable advantages ought to give it. The reluctance with which it is had recourse to is all the greater from the fact that it should be persisted in for several days after the chorea has ceased, in order that its influence be complete. By beginning it again in smaller doses, and for a shorter period, after an apparent cure, relapses may be prevented. This is a rule which I have laid down for myself, but which it is impossible, or very difficult, at least, to follow in hospitals* I shall merely say a word on the use of electricity in the treatment of St. Vitus's dance. De Haeu was the first to recommend it, and his method consisted in drawing sparks from the spine by means of an electric machine or of a Leyden jar. This mode of applying electricity is nowadays justly abandoned, nor has electro- puncture been more successful. As to the good results which are said to be obtained from faradization of the skin, 1 have never been able to verify the accuracy of the statement, and I have not been convinced of its utility by the perusal of cases in which it had been used. I hesitate before having recourse to it when I find that the treatment, in five out of eight cases, lasted from twenty-four to forty- seven days; and when, on the other hand, I hear from the very advocates of the plan that it is attended with certain disadvantages; that it causes such pain, for instance, that several patients had to be rendered insensible by chloroform in order to be faradized. As you may imagine, antispasmodics and narcotics have been used against vol. i.-54 850 ON CHOREA. chorea, such as valerian, camphor, assafoetida, musk, &c., which have been alternately recommended, put aside, and tried again. Of late an interesting memoir has been published by Dr. Corrigan, in the London Medical Times, on the use of Cannabis indica. His first case is that of a little girl, 10 years of age, who had been ill for five weeks. She took five minims of the tinc- ture three times a day, and in eleven days a considerable improvement followed ; the dose was then gradually increased to twenty-five minims three times a day, and the patient was discharged cured in a little less than five weeks. The subject of the second case had been ill a month, and had to be kept under treatment for forty days; she also took twenty-five drops of the tincture three times a day. Lastly, a young girl, aged 16, who had been choreic for the previous ten years, was cured in a month. These cases are not very conclusive, as you see; but I will again say what I told you regarding tartar emetic. Cannabis indica unquestionably possesses an alterative action on the nervous system, and may therefore prove an additional resource in cases of obstinate chorea, and whenever narcotics are indicated with the view of preventing certain dangerous com- plications. I have already told you, gentlemen, that death may be the result of ex- treme agitation, aggravated by sleeplessness, in St. Vitus's dance. Now, chloroform inhalations have been used with benefit by M. Fuster against this agitation. When there is obstinate want of sleep, which gradually exhausts the pa- tient's strength, I have recourse to opium, which I gave, as you saw, to the patient in bed 20, St. Bernard Ward. I administer it in large doses ; and this patient took, for several days in succession, a tablespoonful of syrupus opii every four hours. In more severe cases I prescribe still larger doses of opium. On September 20, 1842, a young woman, aged 20, was admitted into the Necker Hospital (bed No. 27, St. Anne's Ward). She was pregnant, and was suffering from a first attack of chorea, which had set in for the last eight days. Her convulsive agitation was extreme : her limbs, trunk, and eyes were continually moving. Her right leg and arm were paralyzed; her ideas were somewhat confused, and she was strangely talkative, a cir- cumstance which was all the more remarkable that her tongue was affected, and her articulation embarrassed. The pupils were moderately dilated, but sight was good on both sides. Besides having no appetite, the patient could not feed herself; and she could scarcely chew and swallow her food when she was fed. There was no disturbance of the digestive organs except constipation. On the day of her admission I gave her two grains of alco- holic extract of nux vomica, and six grains on the following day. The physiological effect of the drug showed itself five hours after the adminis- tration of the first pill, and lasted an hour and a half. A second pill was, however, given, notwithstanding this, three hours afterwards; but before an hour and a half had elapsed, tetanic jerks supervened, during which she screamed out, and the attack lasted from half-past 7 to 12 p.m. The jerks, in the intervals of which the choreic convulsions returned with still greater violence than before, were such, that the patient jumped up in her bed, and her respiration was interrupted at each paroxysm, her face becoming at first pale and then livid. A strait-jacket had to be used in order to restrain her, and she had it on when I saw her the next morning. On seeing that instead of being quieted, the patient's agitation had been so exaggerated that she had not torn, but worn out, through the violence of her movements, her chemise and the bedclothes, and had excoriated her back, I stopped the nux vomica, and, on account of her want of sleep and ON CHOREA. 851 her extreme exhaustion, I prescribed for her a mixture containing four grains of sulphate of morphia, a fourth part of which was to be taken for a dose, and the whole in twenty-four hours. The patient took three doses, and an hour after the first she fell asleep quietly, and slept for two hours. When she awoke, she remained pretty quiet for four hours; but on her getting excited for some cause or another, she was again as violently con- vulsed as before, so that the remainder of the mixture was given her during the night, and she slept till six in the morning. The choreic symptoms then returning again, I doubled the quantity of morphia, making it eight grains. But it was remarkable that the improve- ment of the previous day was less easily produced this time. The agitation was greater than ever, and although the patient dozed a little after taking the whole of the mixture, she was so excessively agitated in the evening, that my clinical assistant thought fit to prescribe another mixture, contain- ing two grains of sulphate of morphia, and made her take several spoonfuls of it, one after another, in his presence. She became markedly quieter, and fell asleep. Her rest was disturbed at first, but became quiet for the rest of the night after she had taken a few more spoonfuls of the mixture. The next morning, when she awoke, the convulsions returned with nearly the same violence, and I increased the quantity of morphia to 12 grains. For two days she took this dose; and on the agitation appearing again, I successively increased it to 20, 25, up to 30 grains. This last quantity was even given in two doses, but the first dose alone was kept, the second was vomited. In spite of this the same quantity was repeated for two days, and the patient bore it well. The disease at last yielded completely; the patient's sleep became calm and natural, the choreic movements were very slightly marked, and the young woman, feeling comparatively well, re- quested her discharge on October 17, that is to say, after a stay of twenty- seven days in the hospital. You see, gentlemen, what enormous doses of opium can be given in grave cases of chorea. I gave another woman in the Hotel-Dieu fifteen grains of sulphate of morphia, but I do not remember ever prescribing such a large dose as the one I gave my patient in the Necker Hospital. While on this point, let me tell you that medical men dread too much, in my opinion, the use of opium in large doses, in St. Vitus's dance and other grave neuroses; and, indeed, in all cases in which it is indicated. They forget the precept laid down by Sydenham in his letter to Robert Brady, and which he repeats in his admirable letter to William Cole on the subject of small-pox, namely, that " the dose of a remedy should be increased and repeated in proportion to the intensity of the symptoms " (remedii dosis et repetendi vices cum symptomatis magnitudine omnino sunt conferendce). A dose which may be powerful enough to remove a slight symptom will not have any influence on violent symptoms, and a dose which may endanger the patient's life in certain cases will in others save him from certain death. (Quce enim dosis remission symptom ati coercendo par est ea ab alio fortiore superabitur, et quae alias cegrum in manifestum vitce discrimen conjiciet, eumdem ab orcifaucibus liberabitf I have often related the case of a brush-manufacturer, who in 1846 con- sulted me, on account of excessive nocturnal pain in his bones. He had come to take from about six to eight ounces of Rousseau's laudanum, a preparation which contains three times as much extract of opium as the laudanum of Sydenham. He drank it in tumblers in my presence; and added, that on his trying the sulphur baths at Enghien, his pain had been so intensified that he determined on poisoning himself, and took, in one dose, twenty-four ounces of Rousseau's laudanum, that is to say, more than 852 ON CHOREA. two ounces and a half of the aqueous extract of opium. He slept for three hours only. About twenty years ago, I asked Prof. Andral to see in consultation witli me a young man, a friend of mine, who was suffering from an ex- tremely painful neuralgia. We prescribed opium pills of one grain each, which were to be taken until the pain had been subdued. He took twenty- four pills in the space of twelve hours (that is to say, twenty-four grains of gummy extract), and got perfectly well. He was only slightly narcotized ; and now that he no longer needs this remedy, he could not, any more than any other man, take even moderate doses of it without feeling some incon- venience from it. You are aware that in cerebro-spinal typhus, Dr. Boudin gives opium in large doses, proportionately to the gravity of the nervous symptoms. He begins with ten and even twenty grains of the gummy extract, which he gives in one dose, and then repeats every half- hour smaller doses of one and two grains, until the patient falls asleep. Such examples show, therefore, that in the administration of opium, the dose of the medicine is to be less taken into account than the effects which it produces. This is what Peyrilhe meant by saying that when a man is as awake as four, he should take as much opium as five, in order to sleep as one. In grave forms of St. Vitus's dance, therefore, when it is demanded by the excessive agitation and the absence of sleep, opium should be given larga mam. Yet do not believe that this treatment is infallible. It has sometimes failed in my hands, but in such cases, the patients did not only suffer from convulsive agitation in the extreme, and non-febrile delirium, but there was fever present as well as delirium, and nervous symptoms which do not belong to chorea, generally cerebral rheumatism, and opium was powerless against them, as in the sad case which I related to you in the course of this lecture. Lastly, gentlemen, hygienic measures play an important part in the treat- ment of St. Vitus's dance. Thus, nutritious and tonic food taken at regu- lar intervals, open-air exercise, within fatigue, so as to facilitate the organic movements of repair, and to prevent the recurrence of the disease, cold bathing and swimming, are formally indicated. In severe cases of chorea, certain precautions should be taken in order to prevent the patient from hurting himself in his disordered movements. The bed on which he lies should be of sufficient width and thickness, and shut in on the sides by padded flaps, so as to save him from falling. In those extreme cases in which the poor child tears and rubs off his skin, by con- tinual friction against the bedclothes, and when the agitation is such that he is thrown out of bed, over the flaps, a strait-waistcoat is sometimes had recourse to; but instead of diminishing the risks which are dreaded, the chances in their favor are increased, because the strings give rise to excoria- tions of the skin, which afterwards turn into horrible wounds. For my part, I allow my patients all freedom of action ; but I place them in conditions which prevent their hurting themselves. When I was physician to the Children's Hospital, I invented a sort of apparatus which is still used now. It merely consists of a large box, made of deal or of oak, about 2 metres long, 1| metres wide, and metres high, padded with thick and soft cushions on the sides and at the bottom. The child, when placed all naked inside this box, may move about freely without fear of any accident. To protect him against the cold, sheets are either thrown over him, or are made to close the upper part of the box; ora better plan consists in putting hot-water bottles between the walls of the ON CHOREA. 853 box and the cushions. Those boxes are easily procurable for a small sum, and may thus be used in poor families as well as by the rich. Another simple means, namely, waddling the child, is of great utility in very grave cases. It is now several years since it has been recommended, but it is, in my opinion, too rarely employed. The upper and lower limbs of the child are first carefully wrapped in wadding, which is maintained by a bandage, and then the lower limbs are kept closely approximated, and the arms fixed along the sides of the trunk by means of bandages again. I need not add that the turns of the roller which are meant to con- fine the arms, should not be so tight as to interfere with respiration. In general it is found necessary to apply the bandage twice in the course of twenty-four hours. It is a fact that, in the majority of instances, the forced rest in which the muscles are kept calms the extraordinary agitation of some patients. This plan is, of course, had recourse to in very grave forms only. Of the Different Forms of Chorea. Chorea Saltatoria.-Methodical or Rhythmic Chorea.- Tic Douloureux {Chorea Neuralgica).- Tic Non-Douloureux.- Writer's Cramp {Chorea Scriptorum, Functional Spasm of Dr. Duchenne, de Boulogne). Gentlemen : A short time ago, one of my most eminent confreres and I differed as to the diagnosis to be made in the case of a patient who had for more than a year been afflicted with choreic movements. My learned colleague called the disease chorea (meaning thereby St. Vitus's dance), while I was of opinion that it was a form of chorea, but not St. Vitus's dance. Now, I based my opinion on these facts. By questioning the patient's father and the patient himself (a boy, 12 or 13 years of age, and full of in- telligence) on the character of the symptoms, I made out that the voluntary movements remained somewhat regular in the midst of these choreic con- vulsions. Thus the boy declared that he had not lost his usual agility, that he could leap without difficulty, and as well as any of his companions, over barriers; that he could, when going up a staircase, take three or four stairs at a time; that he had no difficulty in skipping with a rope; and lastly, that he used his hands as well as anybody else to feed himself, and even to drink; all which actions cannot be performed, as you know, by persons suffering from St. Vitus's dance. From some obscure disturbance of his nervous system, this child executed curious movements, and was thrown forwards, as if by a spring, by invol- untary muscular contractions, which made him jump to seven or eight feet in front of the place where he might be standing, or get up abruptly, me- chanically (iff may use the expression), from the chair on which he might be sitting; he never fell down. There was a kind of harmony amid this disorder of the locomotor functions, for if all the muscles contracted inde- pendently of the will, they all acted simultaneously at least. This, there- fore, gentlemen, is a form of chorea which differs much from St. Vitus's dance, and to which the name of chorea saltatoria has been given. A few years ago, another instance of the kind came under my notice. A boy was brought to my consulting-room by his father, who had begun to relate to me his case, when he suddenly got up, as if pushed by a spring, jumped on a piece of furniture with marvellous suppleness and agility, and then returned to his chair and sat down quietly. What he had done had shown me the nature of his* case, which his father was going to describe less 854 ON CHOREA. clearly to me. His illness had lasted some time; these singular attacks had set in suddenly, and his intellect had not suffered in the least yet; in the intervals between the paroxysms he was as quiet as possible. He got perfectly well. Although, as in both the above cases, there rarely is an apparent impairment of the intellectual faculties, chorea saltatoria seems to me, however, to belong to the same great class of mental disorders as taren- tism and the epidemic dansomania of the middle ages. It is only a variety perhaps of the methodical or rhythmic forms of chorea, which include chorea festinans or procursiva, chorea rotatoria, and chorea vibratoria. In chorea festinans the individual is irresistibly impelled to run forwards, without being always able to avoid obstacles, or, on the contrary, to go backwards continuously without being able to help himself. This affection should not be confounded with the semi-delirious condition under the influ- ence of which individuals, who are threatened with certain brain attacks, or who are just recovering from an epileptic fit, are carried along in spite of themselves. In July, 1861, I saw, in consultation with Dr. Duclos, a retired military man, about 60 years of age. He was walking with his brother along the banks of the St. Martin Canal, when all of a sudden, without any warning, he began to walk with extreme rapidity, and almost to run. His brother in vain called out to him to moderate his step; he walked quicker and quicker, scarcely avoiding the obstacles in his way, and it was only with difficulty that he could be restrained after more than ten minutes. He stammered, looked strange, and a few moments afterward became slightly hemiplegic in consequence of hemorrhage into his brain. It is pretty prob- able that the first impression produced on the brain by the laceration of its substance was the intellectual disorder manifested by his mad running. The most curious case of chorea festinans which has come under my obser- vation is that of a Havre merchant, who came to consult me in May, 1860. He was with some other persons in my waiting-room, and he got up and trotted into my consulting-room, when his turn came, in such a curious manner that he raised a laugh among the others. His body was stiff and inclined forwards, with his arms hanging straight down along his trunk and thighs, while his eyes were fixed. He ran quickly on tiptoe, taking small steps, as if in fun. When he got near me he stopped and sat down without difficulty. I had seen enough in order to recognize the strange neurosis from which he was suffering. He then told me that these symptoms had come on almost insensibly for about a year; he could no longer go out, felt bodily and mentally weak, and could scarcely conduct the business of his firm. His speech was a little thick. One might, at first sight, think of incipient general paralysis, but with a little care chorea procursiva could be recognized. After he had told me his story, I made him get up and walk slowly, pressing down his foot. He had some difficulty in starting, and seemed fixed to the ground, but still he took the first step forward by himself, and walked several times round my consulting-room slowly. He could therefore command his movements by an effort of the will, while this is not the case in general paralysis or in tremor senilis, St. Vitus's dance, or locomotor ataxy. I found by testing it that his cutaneous sensibility was normal, and his muscular power, tried with Burq's dynamometer, showed no diminution, while, as I shall tell you on another occasion, the muscular power in paralysis agitans (of which, at the end of the year 1860, you saw so curious a case, that of the woman in bed No. 2, St. Bernard Ward) may be so considerably diminished as to mark only 10 lbs. with Burq's dyna- mometer. I prescribed for that gentleman ten turpentine capsules a day (contain- ON CHOREA. 855 ing about 100 minims), which he was to take for twelve or fifteen days a month, and, in addition, I ordered warm baths of several hours' duration. Two months later, when I saw him again, he had improved consider- ably ; I then sent him to the Neris baths, and he had so improved on his return, about the month of August, that I might have hoped for a com- plete cure if I had not been aware how obstinate this neurosis is. Yet he could go into the streets, attend to his business, work, and write, but had always a certain tendency to trot on starting. He restrained himself at once, and could walk more quietly, although with a look of effort and re- straint. On several occasions I made him walk in step like a soldier in my own room-and this is a very difficult kind of walk, which requires great precision of movements. He spent the winter of 1860-61 pretty well, and when I saw him again at the end of May, 1861, he had not lost ground, and I sent him to the Neris baths a second time. I believe that, in some instances, general paralysis and paralysis agitans have been confounded with chorea festinans, but I regret that I have not in my possession notes of cases sufficiently distinct and free from complications that I might give you a complete sketch of this affection. Chorea rotatoria is characterized by rotation or oscillation of the head, or trunk, or of one limb, recurring from 20 to 30, 40, and 80 times a minute. It sometimes terminates in death, and spares neither age nor sex, although it occurs less frequently in children. Chorea oscillatoria consists in irregular or measured oscillations, partial or general, of the head, trunk, or limbs. These singular affections must surely recall to your mind, gentlemen, another kind of partial chorea, which is very common, and which goes by the familiar name of tic. I do not mean tic douloureux, chorea neuralgica, or epileptiform neuralgia, of which I spoke at length in a previous lecture, but tic non-douloureux (spasmodic tic), which consists in instantaneous, rapid, involuntary contractions, generally restricted to a small number of muscles, those of the face usually, but which may also affect the muscles of the neck, trunk, or limbs. Every one must have seen such cases. Thus, there may be only rapid winking, a convulsive pulling of the cheek, of the ala nasi, and of the commissure of the lips, which gives to the face a grin- ning look; or there may be nodding of the head, abrupt and transient con- tortion of the neck recurring every minute; or again, the shoulder is shrugged, and the abdominal muscles or the diaphragm is convulsively agitated ; in a word, the disease may produce an infinite variety of strange movements which baffle all description. The complaint is essentially chronic, and is, so to say, part and parcel of the individual's constitution; he is the only one, sometimes, who does not notice it; it is cured with difficulty; but it is a strange circumstance that it may shift from one place to another. When by treatment, and by exercising the affected muscles, a tic has at last been cured, it may soon reappear elsewhere; thus, it may leave the face, for instance, and seize on the arm or leg. I was lately consulted by a young Englishman who had come from Dieppe, and who was suffering from convulsive and violent movements of the head and right shoulder. After submitting for some time to the methodical gymnastic exercises which I prescribed for him, the tic disappeared from the right side, where it had for a long time been located, but shortly afterwards showed itself in the left shoulder. You re- member what I mean by prescribed gymnastic exercises, and which consist in executing movements, according to order, with the convulsed muscles, and doing so regularly, keeping time to a metronome or a clock. In some cases of tic the patient utters a more or less loud cry, which is 856 ON CHOREA. very characteristic. Once I recognized one of my old schoolfellows (after an interval of twenty years) as he happened to walk behind me, through a sort of barking noise which he used to utter in our school-days. The tic may consist in this cry or bark alone, which is a true laryngeal or diaphragmatic chorea; there is, besides, a singular tendency always to repeat the same word or exclamation, and the person even speaks out loudly words which he should like to keep back. This complaint is very often hereditary. I was consulted by a lady from Burgundy who had spasmodic tic of the face, while her three daughters were suffering from tic affecting muscles in various portions of the body; and the poor mother, who was deeply grieved at the infirmity of her three daughters, and did not notice her own, reproached them with their nervous movements with a bitterness which was curious to see. The hereditary influence may show itself in a different manner. By carefully questioning a patient suffering from tic, you may sometimes find that his ancestors, direct or were all subject to very different neuroses. I saw very recently a boy, 14 years of age, who was afflicted with extremely severe tic, throwing his head sideways with an excessively abrupt gyratory motion, and uttering a small sharp cry. I had seen him before during the summer of 1860, and he then used to utter fierce cries every moment, without his mind seeming to be in the least impaired. This sad condition had lasted several months, and had seemed to improve under the influence of atropine alone. His eldest brother had, for several years, suffered from facial spasm characterized by grimaces, during which all the muscles of his face were violently convulsed. His father has been affected with locomotor ataxy for the last twenty years; his paternal grandfather committed suicide in a fit of monomania, and several of his relations, on his mother's side, have been insane. Writer's cramp or chorea scriptorum is the name given to an affection for which Dr. Duchenne (de Boulogne) has proposed that of functional spasm* It is sometimes a consequence of the overuse of certain muscles, and comes on when these muscles are called into action either instinctively or volun- tarily. Thus, it attacks individuals who write continuously, for a pro- longed period, or with excessive rapidity. It sometimes consists in a spasm, a voluntary, continued, and more or less painful contraction of the extensor and flexor muscles of the fingers, and to such cases the term writer's cramp is perfectly applicable ; but at other times it is true chorea; when the indi- vidual wishes to write, his fingers move more or less violently, shake, or are actually convulsed, so that they are unable to finish what they began to write. Dr. Duchenne (de Boulogne) states that this affection (which is also attended with paralysis) may not only affect the hand, but any other part of the body also, and it is on this account that he proposes for it the name of functional spasm, a denomination which, however open to criticism, has yet the advantage of not particularizing, as that of writer's cramp does. He relates a certain number of cases showing the different localities in which the complaint may be seated. " In writers it may extend to the muscles of the forearm, the hand per- forming a movement of supination as soon as the patient tries to write a word, so that the pen is turned upwards without his being able to pre- vent it. " In the case of a tailor, the arm turned violently inwards, through con- * "De 1'electrisation localises et de son application it la pathologie et a la thera- peutique." 2e edition Paris, 1861, p. 928. ON CHOREA. 857 traction of the subscapularis, as soon as he had done a few stitches. He never had this annoyance when he made any other movement. " A fencing-master found that as soon as he placed himself in a posture of defence, the arm with the hand of which he held his sword, turned im- mediately inwards. " A turner complained that the flexor muscles of his foot upon the leg were thrown into contraction, as soon as he placed his foot on the footboard of his lathe ; but he never felt the same thing when he walked or performed other voluntary movements with his leg. " In the case of a laborer, a paver, both sterno-mastoidei contracted dur- ing the instinctive action of the muscles which keep the head in equilibrium in an intermediate condition between flexion and extension. They did so with such violence, that his head bent down with excessive force. He had only to rest his head against anything in order to stop all contraction; and none took place also when he lay down, or reclined backwards, leaning his head against the back of a chair. " A savant, who had spent several years translating manuscripts, com- plained of the following symptoms which had come on, for the last six months, whenever he read or looked fixedly at anything. His sight, which had been good until then, and which even then was good when he looked about, grew dim whenever he looked at any object for a few seconds. He had double vision, and it could be easily seen that this was due to the spasmodic contraction of the internal rectus of the left eye, which disap- peared as soon as he ceased to look fixedly." The most curious instance of this singular neurosis, which has come under Dr. Duchenne's observation, occurred in a country priest, whose inspiratory muscles were affected. During inspiration, the whole right side of his abdo- men was alternately tense and depressed, while his epigastrium swelled out normally on the left side. A medical man had diagnosed paralysis of the right half of the diaphragm, but the paralysis was merely apparent. The disturbance in the breathing was solely due to the spasmodic and pain- ful contraction of the abdominal muscles on the right side, and of the obliquus externus especially, for at each inspiration this latter muscle could be felt to harden, and the direction of its contracted bundles could even be traced through the emaciated integuments. The spasm was so violent, that the body turned from right to left at every inspiration: it was accompanied with pain, and was a true cramp, which lasted during the whole period of inspiration. This conflict between the inspiratory and expiratory muscles prevented the epigastrium and the base of the chest from expanding on the right side, and consequently prevented the lung from dilating. Hence it was that breathing was considerably impeded, and that the patient had always a choking sensation. There was no fever, and for two years no treatment gave relief. Faradization failed like the rest. I will quote another case in illustration, and from Dr. Duchenne's work again. A Strasburg student, M. V , overworked himself when pre- paring his examination for the degree of bachelier. The excessive strain on his mind, and the efforts which he made to resist sleep, gave rise, accord- ing to his statement, to a sensation of painful constriction in the temples, forehead, and eyes, so that he had been obliged to discontinue his studies. He could not begin reading without this sensation returning at once. Dr. Duchenne found that at such times the eyebrows were pulled up through the contraction of the frontal muscles, and that the eyelids were closed by the contracting orbicular muscles, while the face flushed, and the temporal veins swelled. This condition lasted several years, and was brought on by 858 ON CHOREA. reading alone. The young man committed suicide at last, in despair of ever getting well. Indeed, gentlemen, whatever its seat may be, this complaint is incurable. Absolute rest of the affected muscles can alone prevent it from returning. All treatment has failed. Yet persons suffering from writer's cramp can still write sometimes, by using a peculiar penholder invented by Dr. Caze- nave (of Bordeaux), and the description of which has been given* by Val- leix in his " Guide du Medecin Praticien." I have told you that Dr. Duchenne (de Boulogne) is of opinion that functional spasm may be also characterized by paralysis, and he relates two cases in support of his view, in the memoir which I have quoted. One is that of a bookkeeper, w'hose adductor pollicis lost all power after he had written two or three lines, so that he dropped the pen. He could only write by holding the pen with his index and middle fingers. Yet the muscle could act with energy when- ever he had not to hold a pen : there was no muscular spasm in this in- stance. In the second case, the functional paralysis was seated in the infraspinatus muscle, preventing the arm from rotating from without in- wards, and consequently the forearm, when flexed on the arm, from exe- cuting the same movement. Hysterical Chorea.-Hysterical Cough. Gentlemen : I alluded, in a previous conference, to the case of a girl 13| years old, who occupied bed No. 6, in St. Bernard Ward, and who was suffering from hysterical choreiform convulsions. About the same period, you could see another case of the kind, namely, a young girl 18 or 19 years old, who lay at No. 33, in the same ward. The invasion of the disease, in the latter case, had coincided with a sud- den suppression of the menstrual flux, in consequence of a fright. Convul- sive agitation had immediately shown itself, together with jerking move- ments of the limbs and trunk, so violent as to prevent her from standing. Her tongue was similarly affected; hence she was unable to connect the syllables together, although she could articulate them separately. She stammered in a singular manner, repeating with extraordinary volubility, and for a pretty long time without stopping, the last syllables of the words which she attempted to say, articulating the first syllables with difficulty. It was a remarkable fact, however, that she did not stutter when she sang, and no modification of speech could then be suspected. I at first thought that she was feigning; but this idea could be entertained with difficulty, in presence of convulsive phenomena which lasted a whole day, without a mo- ment's interruption, and ceased during sleep only. On reflecting, however, how painful it is for a healthy individual to move a limb for several min- utes, and a fortiori, to agitate it in the same manner as this young girl did, it could be understood how impossible it must be to act such a part during sixteen or eighteen hours out of the twenty-four, and without interruption. There was a third patient in bed No. 11, who, from her appearance, looked more like a girl 15 or 17 than 12| years of age, as she really was. The attack for which she had been admitted dated only two days back; but she had felt the first symptoms of the complaint six months previously. Her mother was subject to convulsive seizures; one of her brothers, 4 years old, had had several similar ones also; and from her description of the fits they must have been epileptic. Her health had been good until six months * Paris, 1860, t. 1, p. 906. ON CHOREA. 859 ago, when she was suddenly seized, without any known cause, with violent pain in the head and very abundant hemorrhage from the nose, after which she had become extremely weak. Two or three days afterwards her abdo- men had swollen considerably, and she had suffered from colic and gastral- gia. Her appetite was good, however, her digestion regular, and taking- food neither increased nor diminished the pain in the stomach and abdo- men, while the swelling of the latter varied very much. On her admission I found that her abdomen was swollen out to the size of that of a woman in the eighth month of pregnancy ; and the tympanitic resonance heard all over it on percussion was proof sufficient that the distension was due to meteorismus. She complained also of pain in the dorsal region, in the loins and the lower extremities, which she spoke of as cramps in the latter regions. Lastly, the headache continued still. She took very little notice of the above symptoms, when, two days before she applied for admission, she had, without appreciable cause, and without any antecedent emotion, what she termed a nervous attack, which still per- sisted when I saw her. This consisted in convulsive movements, which were at first confined to the arms, and extended to the legs twenty-four hours afterwards. You must have remarked, gentlemen, how, in spite of the choreic convulsions which agitated the limbs during this true chorea, the movements that were performed, however involuntary they might be, were executed with regularity and in harmonious combination. Besides, contrary to what takes place in St. Vitus's dance, they stopped when the patient was asked to stretch out her arm ; she could perform the latter movement with the greatest facility, and in a perfectly straight line. She could take hold, with ease, of any object shown her, reached it directly, and never dropped it after getting it in her hand. Cutaneous sensibility was abolished in certain regions of the body: over the back of the forearm, along the outer aspect of the left thigh, in certain portions of the face and of the chest, there was analgesia; when she was pricked with a pin she felt a mere touch, and had not the sensation of pricking. No doubt could exist as to the nature of her complaint, for she had on several occasions regular hysterical attacks. I met in consultation my colleague and friend Dr. Horteloup in the case of a young lady 19 years old. She had received an excellent education, professed sentiments of the purest morality and of the most enlightened piety, free from all ridiculous show of outward devotion, and was, in one word, a person of sense, whose intellectual and moral condition removed all idea of deceit and of those grimaces with which hysterical girls seem so unaccountably anxious to deceive th,e persons about them, and even their medical attendants when they can. This young lady had lost, eight or ten months previously, a sister to whom she was deeply and tenderly attached. Her grief was all the greater that she keenly felt for her mother as well as for herself. Since that time she had been subject to strange convulsive movements of the head and upper limbs ; yet, when she came to Paris to consult Dr. Horteloup, who had attended her on a former occasion, she was less sad, looked more cheerful, and was pretty easily diverted from her gloomy ideas. When I saw her, her aspect was that of perfect health, but her whole left side was the seat of violent choreic movements-so vio- lent, indeed, that she was in danger of hurting herself against the neigh- boring pieces of furniture or the wallls. If one attempted to arrest these movements by taking hold of her hand, they grew worse, and were accom- panied with a sense of pain, and most unpleasant general malaise. There was one means, however, of quieting all this agitation, as if by magic- namely, by asking her to play the piano. She could spend an hour or two 860 ON CHOREA. at the instrument, playing to perfection, and with the greatest regularity; in excellent time, and without missing a note. She played a piece in my presence with marvellous facility ; and this single fact, even in the absence of other proofs, would have sufficed to show me that this kind of chorea had nothing in common with St. Vitus's dance; for no one suffering from this latter disease is able to do what this young lady did. These illustra- tions, which I might multiply, if it were necessary, suffice to show you the difference which exists between St. Vitus's dance and hysterical chorea. In the latter affection I repeat, however powerless the will may be to pre- vent the disorderly contractions.of the muscles, it can still command com- bined movements, and cause them to be executed with regularity and harmony. When the patient walks she trots, it is true ; but she follows any line which she chooses without deviating from it. If she wishes to carry her hand in any direction, she reaches the end she has in view directly and without difficulty, although her arm may be convulsively agitated ; if she tries to seize an object, she does so at once, without erring ; and when she has once caught, she never drops it, and can carry or place it wherever she likes. I have told you how different the case is in St. Vitus's dance. Thus, if we merely look at the form of the choreic phenomena, it is easy, with a little attention, to distinguish these two kinds of chorea one from the other, as their nature is so essentially different. It very rarely happens, besides, that the former is not accompanied, preceded, or followed by some more special and characteristic symptoms. In the absence of its great manifestations, of its convulsive seizures, hysteria shows itself by that group of perfectly special physical or mental disposi- tions which some authors term hystericism; or there are certain local phe- nomena proper to the disease, such as that strange sensation of umbilical and epigastric constriction, as if a foreign body were going up from the oesophagus to the throat, producing there a sense of choking, to which the name of globus hystericus has been applied ; or, again, perversions of cuta- neous sensibility, which is sometimes exaggerated in certain parts of the body, giving rise to the so-called clavus hystericus, and sometimes, on the contrary, diminished or entirely abolished (analgesia and anaesthesia). Hysterical cough, which is nothing but a convulsion of the muscles of the larynx and diaphragm, presents great analogies to these forms of chorea. However convulsive it may be, it resembles in nothing other convulsive coughs; for instance, the convulsive cough properly so called, which is so frequently observed in children, or that of hooping-cough. It is not, like them, attended with those violent spasms which cause fits of choking, threatenings of asphyxia, and give rise to pulmonary or cerebral conges- tions. A young woman, who occupied for a few days bed No. 1, in St. Bernard Ward, was subject to this cough ; and you had an opportunity of verifying the accuracy of the statement made by my excellent friend, Dr. Lascgue, in his " Memoirs on Hysterical Cough,"* how this kind of cough, when uncomplicated, resembles that which is excited by the inhalation of certain gases-chlorine for example. It is sometimes preceded by a sensation of tickling in the larynx, is dry, or with a trifling mucous expectoration, sonorous, and of a somewhat monotonous rhythm. The patient either coughs at every expiration which succeeds an inspiratory movement, or makes two, three, or four coughing expirations before she begins to breathe again. In the intervals between the paroxysms, the breathing is less deep * "Archives Generales de Medecine," 1854. ON CHOREA. 861 than usual, because the patient dreads deep inspirations, which render the cough more troublesome ; but there is no dyspnoea, and, on auscultation, no other modification of the normal respiratory sounds is detected than a slight diminution of the vesicular murmur at the moment when the inspi- ratory effort is withheld. While it lasts, an hysterical cough has the same rhythm and timbre. The jerks constituting the paroxysm are sometimes so often repeated that it seems as if the latter consisted of a single cough instead of a series of coughs ; but there are intervals of rest between each paroxysm, that are perfectly regular. It is a remarkable fact-which speaks in favor of the analogy which I have sought to establish between an hysterical cough and choreic convulsions-that, however continuous it may have been, it ceases entirely during sleep, and, as Dr. Lasegue justly remarks, this circumstance occurs frequently enough to acquire great diagnostic value. These attacks may recur somewhat periodically, and they may be excited, as well as suspended, by various circumstances which have no influence at all on a cough due to thoracic disease. Tn some cases which are, it is true, very exceptional, an hysterical cough has a peculiar timbre; it is hoarse, stridulous, and resembles a bird's cry; but one should be careful not to confound this cough, which even then retains some of its special characters, with the barking, the mewing, and the strange cries which are heard in hysterical cases, and which are related to the kind of tic of which I have already spoken. An hysterical cough is sometimes complicated with hoarseness and even with aphonia, some- times also with obstinate vomiting, as in the case of a young person who came under nqy notice, and whose history I shall presently relate to you in a few words. Dr. Lasegue makes the observation (in the excellent memqir from which I borrow a good deal of what I am now telling you), that " an hysterical cough not only remains identically the same throughout its course, but has no tendency also to assume other forms of hysteria ; so that there are few instances of such a metamorphosis occurring." He cites, however, two cases which are exceptions to the rule, one of which occurred in Prof. Chomel's practice, and the other was observed in my wards by Dr. Lasegue himself, when he was my clinical assistant. The subject of the latter was a woman who, for the last three years, had been troubled with a cough which lasted almost continuously during several months of the year, recurring with less frequency in the intervals, and having all the characters which I have pointed out to you. She got rid of it after some deep emotion, followed by temporary loss of speech, and two days later by left hemiplegia, evidently of an hysterical nature, which got rapidly well without any treatment. Such cases are not so rare as my learned friend thinks, for it would not be difficult to collect a pretty large number of instances, analogous to the one which Chomel published in the " Nouveau Journal de Medecine," for 1820, of paroxysms of an hysterical cough, alternating with convulsive seizures. I could myself cite several such ; and many among you will surely remember having seen some of them ; and only lately you could see a case of this kind in the wards under the care of Dr. Barth, my col- league in this hospital. Lastly, you will find in one of the late numbers of the " Union Medi- cale," the case of a patient, under Dr. Herard's care, whose hysterical cough was replaced, among other phenomena, by curious sneezing. An hysterical cough may therefore alternate not only with the most common well-developed manifestations of the disease on which it is itself dependent, such as convulsive seizures and attacks of hysterical paralysis, 862 ON CHOREA. but it may also be replaced by local manifestations, such as vomiting and sneezing. What usually happens, however, is this, that the patient has previously exhibited, if not the marked symptoms of hysteria, at least, that group of special physical or mental dispositions which have been termed hystericism by some authors, and which consist in a nervous changeability carried to the highest point. You know, gentlemen, what is meant by nervous changeability, namely, a condition internfediate between spasm and normal visceral innervation. It borders on the state of vapors, immediately precedes, and is a necessary condition of that state, and only requires increased intensity of its phe- nomena, or the excitation of the slightest cause, in order to merge into it. Now this condition, which in most cases is only the highest degree of a predisposition to spasms, and enters into the constitution of many women, is most marked in those that are hysterical. An hysterical cough generally sets in more or less suddenly, and, like all phenomena of a similar nature, without any appreciable cause. In the case of a young woman who came under Dr. Lasegue's observation (the first of the examples which he has collected in his memoir), the hysterical cough came on after a simple cold which had lasted several days. The cold was perfectly well, and the catarrhal cough had ceased completely for the last eight days, when the hysterical cough commenced. You will certainly have an opportunity of seeing such cases. But although bronchitis may prove the exciting cause of an hysterical cough, the latter is by no means dependent on a peculiar predisposition to bronchial catarrhs; and although, from its persistence and obstinacy, it often alarms the patient's friends and even her medical attendant, exciting in them fears that pulmonary phthisis is actually present, or imminent at the very least, I never have seen this complaint begin with such symptoms. In some cases, and always in profoundly hysterical women, a nervous cough sets in, in consequence of the presence of worms. I have already quoted the following instance, which Graves relates in his " Clinical Lec- tures." This illustrious physician was attending, at Dublin, together with Sir Philip Crampton, a young lady who had lost all her strength from a spasmodic cough, which had lasted several months. Although no serious lesion could be discovered by auscultation, both these gentlemen could not help, however, believing in the existence of tubercles in the lungs, for there were fever and considerable emaciation. On the patient taking some tur- pentine, which an empirical old woman recommended, she passed a tape- worm, and the cough disappeared immediately, and her health was quickly re-established. An hysterical cough is an essentially chronic complaint, lasting for months, and even years, uninfluenced by physiological phenomena, such as menstruation, which may occur while it lasts. Intercurrent febrile dis- eases suspend it, however, as they do hooping-cough. When it has persisted for a long time, it influences at last the patient's general health. The appetite diminishes, or is lost, and digestion is impaired, especially if the cough be complicated with obstinate vomiting. The patient becomes pale and thin, complains of pain in the chest, and is unable to bear fatigue; fever is often lighted up; and you can understand how careful one must then be in order to recognize the nature of the case, and how he must have recourse to auscultation and percussion, in order to determine the absence of tubercles in the lungs, which suggest themselves to the mind from the first as the cause of the evil. In spite of its persistence and obstinacy, and of the disturbances which it produces in the system, this singular neurosis almost never terminates SENILE TREMBLING AND PARALYSIS AGITANS. 863 fatally. After lasting more or less, it diminishes insensibly, and then dis- appears completely; in other cases it ceases suddenly, without any reason to account for this happy and abrupt termination. But whether it ceased by slow degrees or suddenly, the cure may be merely temporary. Like all hysterical manifestations, the cough may return at the very moment when the patient thinks that she has got rid of it forever; and, as on its first ap- pearance, it comes on without any appreciable determining cause. Of all the methods of treatment which have been tried against an hys- terical cough, one alone has seemed efficacious to me, and I have rarely seen it fail, namely, change of place; and the following case, to which I have already alluded, proves this most conclusively: A young lady, 17 years of age, whose health was habitually good, al- though she looked delicate, and who menstruated regularly, began to cough in May, 1852. Her mother was subject to spasmodic tic of the face, but she had never had any nervous attacks herself, although she had all the characters of an hysterical temperament. This cough attracted little notice for the first few days, but became so frequent that it alarmed her friends. It kept on all day, nearly without intermission, but ceased entirely when the patient slept in the daytime or at night. It was dry, sharp, stridulous, acute; audible from a pretty good distance, and recurring with a nearly unchanged rhythm. The most varied remedies-baths, cold affusions, anti- spasmodics, &c.-were tried, but without modifying its frequency or its characters. The breathing was such as to leave no doubt as to the regu- larity of the pulmonary functions; the fauces were neither red nor pain- ful, and there was no alteration of the voice. This condition lasted through- out the months of May and June; in the beginning of July some fever set in; digestion had already become laborious, and the appetite was nearly lost; vomiting came on, and the patient brought up her dinner half an hour after taking it, but not her morning meal. As her general health seemed to me to be rather seriously impaired, I recommended that she should be immediately sent to the South. My advice was acted upon; and on arriv- ing at Orleans, after a three hours'journey, the patient, who felt fatigued, spent the night in a hotel. The vomiting ceased on that very day; the patient spent a good night, and had no fever; on the following day the cough ceased, and a complete cure ensued, which has lasted ever since. She remained away besides for several weeks. A few years ago I saw, in consultation with my colleague, M. Guibout, a lady, 27 years old, who, for the last six months, had been suffering from a cough, having the peculiar rhythm which I have described to you. She had lost her appetite, had become ansemic and thin, and this alarmed her friends considerably: yet nothing abnormal could be detected on auscult- ing her chest with the greatest care. We prescribed a travelling-tour, and she got well immediately. LECTURE XLVII. SENILE TREMBLING AND PARALYSIS AGITANS. Gentlemen : I told you in our conferences on St. Vitus's dance that it could affect individuals of advanced age, although it most frequently at- tacked young adults, and I quoted in illustration a long and interesting 864 SENILE TREMBLING AND PARALYSIS AGITANS. case published by Dr. Henry Roger, the subject of which was a woman, 83 years old. This kind of chorea should not be confounded with another, namely, chorea senilis or senile trembling, as it is more appropriately term- ed, from which it differs totally, not only as to its nature, and the condi- tions which favor its development, but also as to the form which its symp- toms assume, so that the two diseases may be easily distinguished from one another at first sight. Senile trembling consists in a convulsive agitation of the muscles, pro- duced by a series of involuntary but uniform contractions, taking place over a limited area, and following one another with excessive rapidity. At first generally confined to the extremities or to the muscles of the neck, it may spread to the whole of the body. It is most marked when the in- dividual tries to execute voluntary movements, or when his mind is un- usually stretched, or when he is under the influence of emotion. Rest and peace of mind diminish its violence or make it disappear entirely, while it ceases completely during sleep. The causes of this complaint are unknown. It is usually said that this kind of trembling is a consequence of the weakness which old age brings on, but if this be true in some cases, it is not so generally speaking. For on the one hand, it is not invariably seen in very old people, and on the other hand, it pretty frequently affects individuals of middle age, and even young adults. You have yourselves known instances of this; and on this account, therefore, the term senile, when applied to this kind of trembling, is as inappropriate as when it is applied to gangrene due to the oblitera- tion of an artery, and which may be seen at all ages, even in childhood. However this may be, this kind of chorea is little known to pathologists, although it is pretty common. One point, however, is well known about it, namely, that it is incurable. Senile trembling should not also be confounded with paralysis agitans, of which the woman now at No. 2, in St. Bernard Ward, presents us with an instance. She is a charwoman, aged 60; her complaint dates two years back, since which time, but especially for the last six months, she has com- plained of rapid loss of strength. Since then also she has been subject to trembling which, from being slight at first, became so violent that for the last four months she has been obliged to give up her usual occupation, from her inability to use her hands. The trembling has since become more general and involved the face, so that now her lower jaw shakes convul- sively ; and as she cannot shut her mouth, she dribbles constantly. She has retained all her faculties, and although she complains of the annoyance caused by this perpetual shaking which she cannot restrain, she does not speak of pain but only of a sense of extreme fatigue after the paroxysms of trembling. This is more marked on the right than on the left side, and when the strength of her right arm is tested with the dynamometer it is found to be equivalent to a power capable of raising a weight of 14 or 16 lbs., while on the left side, the instrument gives only 4 to 6 lbs. Cutaneous sensibility is unimpaired. In spite of this marked diminution of her mus- cular power, there is no paralysis properly so called, for when I try to flex or to extend her legs or her arms against her will, she resists me with an energy which I only overcome with some difficulty. I called attention, as you may remember, to the shape of her hands, for her four fingers deviate from their normal direction, and inclining towards the ulnar side of the limb, form with the forearm an angle of about 25°, so that the metacarpo- phalangeal articulation must, therefore, be partially dislocated. Paralysis agitans, like senile trembling, is principally met with in persons SENILE TREMBLING AND PARALYSIS AGITANS. 865 of declining years, although it may affect adults, and I have seen a young man, 27 years of age, who was suffering from it. In some cases it assumes another form, which it is important for you to know. . • On October 16, 1863, I was consulted by an advocate, aged 58, of un- common intelligence, and who for the last four years, after deep emotions, had been affected with the singular neurosis which I am going to describe to you, and which, in my opinion, was only a form of paralysis agitans. As he came up from the waiting into my consulting-room, he inclined his body forwards, hurrying his step, with his right arm, in a semiflexed posi- tion, resting against his body, and shaking very slightly. He sat down with some difficulty, and as if his trunk and legs were stiff He then told me his story; how, in 1858, he had for more than a twelvemonth attended his wife assiduously, whom he loved deeply and had lost. Grief and sleep- less nights had exhausted him. He was then suffering from such nervous irritability that he could not bear to hear the ringing of bells; the least noise, the least annoyance, disturbed him beyond measure. He soon noticed that his arm seemed to shake slightly, and that the movements of the whole limb, but of the hand especially, became more and more diffi- cult. In a short time, the leg on the same side became affected also, and his symptoms grew worse, without being in the least modified by any method of treatment. After a time, he had to give up writing, and when I saw him, he could sign his name with extreme slowness and difficulty only. At first sight, he looks like a paralytic but on examining him carefully, it is soon made out that there is only apparent paralysis, and that the case is a very curious one, which we cannot account for. For if I ask the patient to squeeze Burq's dynamometer, the instrument marks 100 lbs. much more than it does when I squeeze it myself. Squeezed by the patient's left or healthy hand, it marks 84 lbs. only, that is, 16 lbs. less than when the hand of the seemingly paralyzed limb is used. If, when his arm is flexed, I try to extend it against his will, he resists me with ex- treme energy, and does the same when I attempt to flex, adduct, or abduct it against his will. There is no rigidity of the limb, and when the patient does not exert his will, his limb is perfectly supple and I can move it in every direction. What takes place here then ? The muscles have retained their strength, and yet their functions are nearly abolished. But let us try and analyze this curious phenomenon. When the will commands, the muscles obey in- stantly, and no appreciable interval intervenes between the act of willing and the muscular contraction. The movement may be repeated ten, fifteen, twenty, a hundred, or a thousand times in succession, as in the act of walk- ing, for instance. If you suppose that in order to take two steps, the muscles have to expend an amount of strength equal to twenty pounds, if the same act be repeated a thousand times in an hour, a power of twenty thousand pounds shall be expended. Now, let us see what occurs in the case of the patient whose history I have related to you. Let us suppose that he takes five hundred steps in an hour; each step shall have cost a 20-lb power, and he will spend on the whole a force equal to ten thousand pounds, instead of twenty thousand, or, in other words, the motor power will be only one-half of the other. It was a very strange circumstance, that when I asked this patient to open and shut his hand as rapidly as he could, he moved at first quickly, then more slowly after scarcely a quarter of a minute, and next he was unable to move at all. Just as a steam-engine, which is insufficiently heated, is vol. i.-55 866 SENILE TREMBLING AND PARALYSIS AG1TANS. unable to work continuously. But if the valves be closed for a moment, and the steam allowed to accumulate, the machine regains power for a time, but soon becomes powerless again after this artificial development of force. Ph the ease of our patients, it would seem as if they could only spend a determinate quantity of nervous influence which is not reproduced in them with the same rapidity as in other men. They suffer then from a relative and momentary loss of power, but not from paralysis in the ordinary ac- ceptation of the term. The patient, whose history I have just related to you, was suffering from that form of the disease in which there is but slight shaking. The other woman, on the contrary, who was in bed No. 2, in St. Bernard Ward, pre- sented considerable muscular agitation. In the man's case, the muscles were in a state of permanent contraction, and the sensation complained of was that of a continuous effort. In the woman's, on the contrary, although that sensation was complained of from time to time, there was more fre- quently muscular agitation. She stated that every paroxysm of shaking caused her as much fatigue as very violent exercise used formerly to do. By endeavoring to analyze these two muscular conditions, we shall under- stand better what occurs in what has been so inappropriately termed paralysis agitans. All our muscles are in a state of relaxation during the period of rest. Their function ceases temporarily, and during that rest the aptitude which was lost or diminished from excessive action, is entirely regained. Sup- pose now, that in consequence of a modification of the nervous centres, the muscles should always be in a condition analogous to that of continuous effort, their excitability will be exhausted during their immobility, from the extensor and flexor muscles acting constantly and simultaneously. In the other form, the alternate rapid and involuntary movement of extension and flexion which constitutes trembling, expends the nerve force, as rigid- ity did in the former case, and power is wasted uselessly, at the expense of normal functions, so that when it becomes necessary to exhibit muscular power, the patient is incapable of doing it with the same continuity, or in the same degree, as before, and he will be in the same condition as an indi- vidual exhausted by extreme fatigue. We meet with an analogous condition in those cases which I have termed loss of muscular excitability, a curious neurosis, of which I have seen very interesting instances. A young lady, aged 18, and married for the last six months, came from Tours to Paris a few years ago, to be treated for this strange neurosis. She was said to be paralyzed. When I asked her to walk, she got up with determination, walked without staggering, and with perfect steadiness, ten, fifteen, twenty, twenty-five paces, then complained of feeling weak, and if no chair were near at hand, she was compelled to sit down on the floor. She lost all strength after this trifling exercise, and- exhausted the amount of excitability possessed by her muscular nervous system. A few minutes' rest sufficed to give her back the aptitude which she had lost. In 1862 I saw another young lady in precisely the same condition. Mark that these two cases are only exaggerated instances of what we very frequently see. The power of restraining movements varies indefinitely, and we have no right to look upon these two cases as instances of paralysis, any more than we can pronounce those whose strength is exhausted after a moderate exer- cise lasting from ten to twenty-five minutes, to be suffering from paralysis. It must be a well-understood point then, gentlemen, that there is no paralysis at the commencement of this strange form of chorea, which is so inappropriately termed paralysis agitans,.since there are cases (an instance SENILE TREMBLING AND PARALYSIS AGITANS. 867 of which came very recently under my observation) in which the muscular power, tested by the dynamometer, is, temporarily at least, greater on the shaking than on the opposite side. In the long run, however, real weak- ness supervenes, and towards the close of the disease the loss of muscular power is such that the existence of paralysis cannot be denied. Yet, it should be observed, that sensation is unimpaired. The weakness of the genito-urinary organs is still more marked than that of the muscles. In males impotence sets in rapidly, and towards the last the urine is retained with difficulty, and there is sometimes incontinence, which may, however, be due to continued tonic contraction of the fibres of the bladder. There may also occur another phenomenon which makes paralysis agitans resemble very much paralysis, due to hemorrhage into, or softening of, the brain, namely, rigidity. I was consulted, in 1863, by a superior naval officer, who for the last two years of a difficult command had been affected with paralysis agitans. At the end of a year he lost the power of writing, and when I saw him for the first time, the two last fingers of his right hand were firmly flexed into the palm of the hand, and it was only with slowness and with extreme difficulty that he could extend his thumb and his index and middle fingers. Paralysis agitans, which some authors of eminence have confounded, not without some reason, perhaps, with chorea festinans, is partial in the begin- ning, and may affect one arm alone, for instance. The limb shakes con- tinually, and the patient complains of its feeling weak; this weakness, which is very slight at first, makes rapid progress; the corresponding leg shortly becomes affected in the same way, and involuntary convulsive movements show themselves simultaneously with a sense of diminution of muscular strength. The patient only hops when he tries to walk. As the disease progresses, it becomes general; the limbs of the opposite side are involved, and the patient's gait then becomes so characteristic, that his complaint can no longer be mistaken, although it cannot be satisfactorily described. His body inclines forwards as he walks, and he keeps the arm on the affected side in a semiflexed attitude, and closely pressed against the trunk. As his centre of gravity is thus displaced, he is obliged to run after himself, as it were, so that he keeps trotting and hopping on. He is unable to move without help, and in some cases, as he requires more assist- ance than is afforded by leaning on a stick, he can only walk by resting both his hands on the shoulders of an attendant, or supported from behind, otherwise he is sure to fall down. I must add, however, that the complaint always occurs in paroxysms, and that after a paroxysm which may last from ten to forty minutes, and even more, the patient complains, not of pain, but of a sense of muscular fatigue, as after violent exercise. When the disease becomes still more general, the muscles of the neck are convulsed, and the head then shakes continually; the muscles of the face are not spared, and as you saw in the case of the woman in my wards, the lower jaw drops, the mouth is always open, and allows the saliva to dribble out, which wets and messes the patient's clothes. Speech is, of course, em- barrassed and indistinct. On the other hand, as the bladder gets paralyzed, there supervenes retention, and subsequently incontinence of urine. All sexual power is lost. The convulsive movements are so often repeated, although they are not violent, that deformities result from them. Thus, from the patients' pressing against their hands constantly, their fingers get dislocated on the metacarpal bones, and their dorsal surface makes an angle with the back of the hand. 868 SENILE TREMBLING AND PARALYSIS AGITANS. The intellect is at first unaffected, but gets weakened at last; the patient loses his memory, and his friends soon notice that his mind is not so clear as it was: precocious caducity sets in. Paralysis agitans is an inexorable complaint, which always terminates fatally within a shorter or longer period, in spite of all treatment. In three cases, however, which were under my observation until the end, I made the curious remark that death was caused by pneumonia. There is little prob- ability that other practitioners shall have an opportunity of noticing a similar coincidence between a neurosis and pneumonia. I am not aware that the anatomical lesions special to paralysis agitans have been studied in France, and it seems that those who looked out for them, did not find any. We must pay great attention, however, to the alterations which Parkinson, Oppolzer, and Lebert have described; and allow me to quote a case, most carefully observed by Professor Oppolzer. A man, aged 72, very thin and of very diminutive stature, was admitted into the "Clinique" on June 20, on account of a violent trembling which prevented him from using his hands. He gave the following account of the origin of his complaint: he had never had a serious illness until the age of 60, when during the bombardment of Vienna, in 1848, he happened by chance to get in the midst of the fight. He was struck with such terror, that he could not return home by himself, and had to be taken there. He had scarcely got over his fright, when a bomb burst near his house and alarmed him again. A few hours afterwards, on trying to take some food, he found himself perfectly unable to use his hands, because as soon as he tried to move them, they began immediately to tremble violently. He noticed also after a short time that his lower limbs trembled in the same manner, but less violently, so that he could still walk. The disease not only resisted all the measures employed against it, but also grew gradually worse. The trembling persisted even when he was at rest, and involved other muscles; lastly, paralysis was superadded to it. After a few years, he became incapable of standing erect, and as soon as he made the attempt, he had an irresistible tendency to fall forwards, so that in order to avoid falling down, he was obliged to lay hold of neighboring objects, or to walk hurriedly. The keenness of his senses and of his intellectual faculties had diminished slowly but progressively. The use of tea, of coffee, or of spirituous liquors always increased the trembling; and the agitation of the lower limbs was especially marked in the evening, when the patient had walked during the day. About six months ago, the sphincters, that of the bladder, in particular, became para- lyzed ; the patient was then admitted into the general hospital on account of these complications, which seemed to improve at the end of a month. Five weeks ago, after a severe attack of vertigo, the patient dropped down suddenly, and was unable to rise, but never lost consciousness through- out. Since that time, the emaciation has increased very rapidly; the patient can stand and walk for a very short time only, and with very great efforts ; and in addition, his articulation is embarrassed. He was in the following state when admitted into the Clinical Hospital: emaciation very marked; earthy tint of the integuments, the surface of which is covered with numer- ous epithelial scales ; the secretion of perspiration, which is increased on the face, seems on the contrary to be diminished in other regions of the body; the temperature of the skin seems to be lower than it normally is. The muscles of the face, tongue, neck, and upper limbs are affected with violent trembling, which never ceases during the waking state, and is com- pletely suspended only during profound sleep. The lower limbs shake periodically only, and when there is general exacerbation of all the symp- SENILE TREMBLING AND PARALYSIS AGITANS. 869 toms. The muscles which are the seat of the trembling are rigid at the same time, especially the muscles of the neck and shoulders. The pupils are equally dilated, and contract equally well under the influ- ence of light. The mouth is only incompletely closed, and the saliva dribbles out of both corners over the chin. There seems to be no visceral lesion; there is merely slight dulness in front and at the back over the apex of the right lung. Auscultation detects besides, at those spots, a diminution of the respiratory murmur. The temporal arteries and the arteries of the limbs, especially the right brachial, are tortuous and rigid. Sensibility is normal everywhere; and the muscles contract, although somewhat feebly, under the influence of galvanic excitation. The patient frequently complains of vertigo, and more rarely of cephal- algia. The stools are passed normally; the urine is alkaline and contains some pus. The patient answers very slowly but pretty clearly the questions which are put to him. His physiognomy is expressive of indifference and apathy. Treatment: carbonate of iron (a drachm for six doses to be taken in three days). The following is a summary of the further progress of the case: From the 22d to the 24th of June, a pretty severe diarrhoea set in, with involuntary stools, which yielded to the use of opiate injections. On the 24th, the carbonate of iron, which had been suspended during the presence of diarrhoea, is resumed. June 25. The patient slept only a little last night, and was delirious: about ten in the morning, he had an epileptiform seizure, during which his head was pulled convulsively to the right, while his right eye turned out- wards and upwards, and his left eye downwards and inwards. The eyelids and the tongue kept at the same time oscillating continually, while the muscles of the face were rigid and hard. The upper and lower limbs, on the contrary, remain flaccid, offering little resistance when moved about. The fit lasted about eight minutes, and during that time, the respiration and the pulse were weak and irregular, and there was complete loss of con- sciousness. On the 1st and the 7th of July, fresh eclamptic seizures came on, after which, on each occasion, the trembling ceased for about half an hour, recur- ring after this with its former severity. General sensibility seemed to diminish from day to day, and the face had a stupid expression, reminding one of the physiognomy of individuals laboring under typhoid fever, in the second stage. The abdomen was swollen ; there were involuntary stools, the urine contained some carbonate of ammonia and a few pus-cells as before; the patient lay in a sort of imperfect sleep, and it was almost im- possible to fix his attention. He answered in monosyllables the questions that were put to him ; his strength diminished rapidly, and pneumonia came on towards the close of his life. Death took place on July 11. On making a post-mortem examination, several tubercular cavities were found at the apex of the right lung, and there was granular hepatization of the lower lobe of the same lung. Both ventricles of the heart were dilated and full of coagulated blood; their walls were discolored and friable ; the aortic valves were indurated at the base, the arch of the aorta dilated and ossified, the spleen of voluminous size, the mucous membrane of the bladder red, injected, and the muscular wall of the organ likewise injected. The other abdominal organs presented besides no other notable alteration. The cranial bones were very thin, and their inner surface was rough. The dura mater was thickened and adherent, here and there, to the inner table of the cranial vault; the pia mater opaque and infiltrated with serosity : there was also a pretty large quantity of serosity in the subarachnoid cel- lular tissue. The cerebral convolutions were thinner, the sulci between 870 SENILE TREMBLING AND PARALYSIS AGITANS. them seemed deeper than usual, the cortical substance was of a pale brown color, while the medullary was perfectly white, and traversed by dilated vessels; the cerebral substance was moist and of good consistency. The ventricles contained several drachms of transparent serosity, and the epen- dyma, principally on a level with the posterior cornu, was granular. In the substance of the right optic thalamus there was an apoplectic cyst of the size of a small bean, the walls of which contained pigment. The pons Varolii and the medulla oblongata were very manifestly indurated. The spinal cord was firm, and the medullary substance of the lateral columns, prin- cipally in the lumbar region, presented opaque gray striae. On making a microscopical examination, there was found in the substance of the pons Varolii and of the medulla oblongata an abnormal production of connective tissue, accounting for the induration of those parts. The opaque strice in the lateral columns of the cord were due to the presence of connective tissue in process of development. In this case of Professor Oppolzer, then, gentlemen, the medulla oblon- gata and the pons Varolii were found indurated, while in the lateral columns of the cord, especially in the lumbar region, the medullary substance exhibited gray opaque striae. All these changes, as well as the analogous ones noted by Parkinson and by Lebert, were the result of an hypertrophy of the connective tissue which enters into the composition of the nervous tissue. This hyperformation had produced compression of the nervous elements, whence their atrophy and fatty degeneration. Such alterations, attended with induration of the affected parts, are termed sclerosis. In the cases in which dissection has shown incipient softening of the columns of the cord, in the same regions, this may perhaps have been a consequence merely of hyperajmia and vascular dilatation, which cause great modifica- tions in the nutrition of nervous elements. Such alterations account for the powerlessness of treatment, for none as yet seems to have been attended with certain and continued success. I must mention, however, that Elliotson has ascribed the cure of a case of paralysis agitans, in a man 35 years of age, to the administration of carbo- nate of iron. But he admits that he was completely successful in one case only, and that no appreciable improvement was obtained in others. Romberg tried the same treatment, and states that it failed; so that, although we may ascribe some part of the cure to the carbonate of iron in Dr. Elliotson's case, we may ascribe as great a share to the patient's age as to the medicine itself. Sulphur baths, iodide of potassium, and all power- ful alterative remedies, should be tried, especially with the view of placing the patient in the most favorable condition for resisting the progress of the disease. Perhaps also, as in a case published by Dr. Axenfeld, the hyper- semic process which goes on might be arrested by revulsives applied to the upper portion of the vertebral column. I have myself, in some cases, obtained good results from the use of large doses of spirits of turpentine, and from hydropathy; but I have not cured a single patient: and this sad complaint is, in my opinion, as intractable as progressive locomotor ataxy. CEREBRAL FEVER. 871 LECTURE XLVIIL CEREBRAL FEVER. Instances of Different Forms of Cerebral Fever.-Description of the Disease: Three Stages which are generally pretty Distinct.-Premonitory Stage, char- acterized by a Group of General Phenomena, which may be seen in other Diseases, but which are never so Marked and never so Prolonged as in this Complaint.-Second Stage: Absence of Fever; the Pulse becomes re- markably Slow, and the breathing peculiarly Irregular.-This Irregular- ity of the Respiratory Movements is a, Sign of Great Value.-Differential Diagnosis between Cerebral Fever and Typhoid Fever.-Third Period: The Pulse Quickens again, and often to an Extraordinary Degree.- Prostration, Delirium; Convulsions, at first Partial, then General; Pa- ralysis.- Cerebral Fever is nearly always, not to say always, Fatal, what- ever be the Treatment adopted.-The Post-mortem Appearances are more indicative of Cerebro-Meningitis than of Meningitis.- Whether Tubercular or not, the Complaint runs the same Course.-Chronic Hydrocephalus.- It is not a Consequence of Cerebral Fever. Gentlemen: At No. 33, in St. Bernard Ward, there died a young woman, 23 years old, who had been admitted on March, 13, 1866, on account of paralysis of the right limbs, without implication of the face, and due to cervical arthritis, marked externally by great swelling of the first vertebrae, and by pain exaggerated by the least movement of the head, which, on that account, the patient kept perfectly motionless. The paralysis had supervened under the following circumstances. The patient stated that she had in general enjoyed good health, although she was of a delicate constitution. Eighteen months before she was admitted into the Hotel-Dieu she was seized with pain in the neck, acute enough to prevent her from turning her head, especially to the right, She had at the same time a sensation of constriction and stiffness in that region, which was markedly swollen. Ointments (the composition of which she could not tell us), poultices, and subsequently the application of leeches, did not arrest the progress of the disease. Within ten months the complaint had made such advances that the poor patient could no longer lie with her head on the pillow, as the pressure exaggerated her pains, which were much worse on the right side of the neck. She complained at the same time of a sense of constant numbness in that part. The phenomena of the disease soon assumed a more complicated form, and fifteen months after their invasion she complained of a diminution of strength in the right arm and leg. This weakness went on increasing, and in a month's time passed into paralysis, which never was complete, however. The patient could still walk, although she could only raise hdr leg with difficulty, and dragged it; she had not lost entirely the power of moving her arm, although she could not use her hand to do her customary work, not even to carry her food to her mouth. Formication, followed by numbness, preceded and accompanied the paral- ysis of motion, and was the only disorder of sensibility, which was, in other respects, perfectly normal everywhere. There was no impairment of the 872 CEREBRAL FEVER. intellect; the special senses were normal, and there had been at no time the least febrile reaction. For the last two months or so the appetite alone had failed, and the patient ascribed it to her being unable to take as much exercise as before. Her digestion was perfectly regular, notwithstanding. From the first day that I saw her, I easily made out that the hemiplegia was due to disease of the vertebrae. My attention was attracted by the swelling of the neck, which was much larger superiorly on the right, espe- cially on a level with the two first cervical vertebrae. The swollen part was painful, and the least movement of the head, either when the patient herself attempted to raise or turn it, or when I tried to move it with great caution and slowness, was attended with acute suffering. The case was evidently one of white swelling of the atloido-axoidean articulation; and although auscultation of the chest revealed no signs of pulmonary tuberculization, and the patient declared that she was not liable to colds, and that there was no tendency to phthisis in her family, I could not but diagnose scrofulous disease of the vertebral column. Although I could not discover any trace of syphilitic diathesis, still suspecting that the disease might arise from constitutional syphilis, I prescribed mercury (corrosive sublimate baths and calomel in divided doses); but as salivation was soon induced, I suspended the calomel. The disease continued to make progress. In order to calm the pain, which had become more intense, I ordered poultices, made with powdered couium leaves, and kept on the neck day and night. The pain still went on increasing, and it was not only felt in the head by July 17, but in the legs also, the hypogastrium and the groins. As menstruation (which had been regular until eight mouths ago) had been suppressed at that time, I thought that the pain might be due to a tendency to a re-establishment of that function, but vomiting having set in, I began to fear that it might announce the invasion of a cerebral affection. Indeed, in the course of the day the patient, whose mind was perfectly clear, began to exhibit some embarrassment of speech. The pain in the neck grew much worse, the paralysis of the limbs became more marked, and by the next day the ex- pression of the face had altered appreciably. The disease remained stationary until the 23d: calomel, which had been resumed on the 18th, was continued in the same divided doses. The drug had no apparent effect on the digestive tube, and the stools were regular as usual. On July 23, we found strabismus, and for several days previously the patient had complained of seeing double. On the 24th, deafness came on ; the patient had an attack of syncope during the night, and on the next day I found her in a feverish state, with a hot skin, and the pulse beating at the rate of 120 in the minute. The abdominal walls were retracted and boat- shaped ; the cerebral macula was produced with the greatest facility, and persisted for a long time. The patient had fits of absence during the day, and did not know the persons about her; delirium set in during the night, but disappeared in the morning. The strabismus, and the changes in the expression and the color of the face, which was alternately very red and of a deadly pallor, became more and more characteristic, and in the even- ing, the stools were passed involuntarily. The symptoms grew worse and worse. The respiration became very irregular, from four to five or eight inspiratory acts following one another with extreme rapidity, and being then followed by a considerable pause. There was extreme vascularity of the skin, and the cerebral macula was brought out by the least friction ; the strabismus was pushed to its ex- tremes! limits, and the pupils were dilated. The intellect was still pretty clear, CEREBRAL FEVER. 873 and the patient answered questions, but without separating her teeth, her jaws being firmly closed. Death took place on July 28, at 4 p. m. You remember, gentlemen' what we found on examining the body. I had, during life, diagnosed white swelling of a vertebral joint as the start- ing-point of a cerebro-meningitis of the base, and, indeed, we found traces of a violent inflammation of the pia mater, which was infiltrated with pus, and covered as with a greenish transparent veil the annular protuberance and the space between it and the optic commissure. The fissure of Sylvius was filled with a sero-fibrinous material. On making sections of the brain, the fornix and the septum lucidum were found in a pulpy condition; the lateral ventricles contained a notable quantity of serosity, and their posterior part was softened as well as the corpus callosum. There were no tubercles, and no granulations anywhere. The spinal meninges were injected, and the cord itself was softened on a level with the articulation of the atlas with the axis, while those vertebrae, which were markedly larger on the right than on the left side, exhibited all the characters of osteitis. Their articular surfaces and that of the odontoid process were deprived of cartilage, rough- ened, and pierced with numerous foramina, but they contained no tubercular matter, either collected in masses, or in a state of infiltration. The cellular tissue in the neighborhood was infiltrated with plastic lymph and with pus. The lungs looked healthy, and showed no traces of tubercular deposit. About the same time as this patient was admitted into St. Bernard Ward, another young woman died there also, but much more rapidly, of cerebral fever, which had supervened under different circumstances. She came to the hospital during the day, stating that she had been unwell for the last nine or ten days. She gave a pretty good account of her sensations, but seemed by no means uneasy about them; she laughed at and joked about her own condition (note this well, gentlemen). Yet, I was far from being satisfied with her state. I noticed that her face was flushed, her aspect dull, her pupils dilated, and that her left limbs were somewhat weaker than the right ones; the cerebral macula was produced with the greatest facility. AV hen my clinical assistant saw her in the evening, he diagnosed encepha- litis, and I made the same diagnosis the next morning. Three days after- wards the patient died. She had conversed with me very pertinently on that very same morning, and had even joked, but an hour after my visit, she fell into a profound stupor, and died suddenly. Dissection disclosed on the surface of the brain, at its upper and under aspects, the presence of granulations in the meninges, and a small mass of tubercle at the base. The corpus callosum was completely softened, and reduced to a pulpy condition, as well as the posterior part of the walls of the lateral ventricles, the cavity of which contained some serosity. The septum lucidum and the fornix were also softened. Some of you may also recollect the history of a third patient, a male, who died of cerebral fever about the same time as these two women. He occu- pied bed No. 19, in St. Agnes Ward. He was 21 years old, and had been seized, about eighteen months previously, with rheumatic pain in the left leg, which resisted all treatment. Two months before the complaint, of which he afterwards died, set in, he came to Paris and took a situation as shop messenger. He worked beyond his strength at that place, he says, and a fortnight before his admission into the hospital he complained of a violent pain in the head, which set in suddenly. He went on working as usual; but he felt so exhausted every evening that he could scarcely find strength to get home. Three or four days went by. His appetite had failed sensibly for about a month, and since he had come to Paris he had been subject to diarrhoea, passing two or three liquid stools in the twenty-four hours. Dur- 874 CEREBRAL FEVER. ing the above three or four days he had lost his appetite completely, and he soon was compelled to give up work. His headache increased markedly in violence, especially across the forehead, at'which part he complained of continued, unbearable throbbings, giving him the sensation as if his skull was going to burst. He had pain in the eyes also; and did not sleep at night. From the beginning, he had had during the day very copious vomiting, and could keep no liquid on his stomach. The matters which he vomited contained bile; and he complained of a bitter taste in his mouth. The tongue was coated with a thin, whitish fur; the skin was not abnor- mally hot, but the slowness of the pulse (which beat 25 times in the minute) coinciding with intense cephalalgia, sleeplessness, and dilatation of the pupils, made me anxious. Constipation had replaced the diarrhoea, and in order to produce revul- sion towards the lower part of the large intestine, I prescribed a purgative (calomel and jalap). On the next day the pulse was slower, 46 ; the vomiting was less frequent, but the cephalalgia being still more violent, if possible, I tried to relieve it by the application on the forehead of compresses steeped in a solution of cyanide of potassium (20 grains to 3 ounces of distilled water). The pain began to diminish forty-eight hours afterwards; but the patient had com- plained for the last three days already of some disturbance of vision ; his eyes looked like those of a drunken man ; the pupils were not dilated to an extraordinary degree, but contracted badly under the influence of light. Lastly, the cerebral macula was easily produced. In the course of that even- ing (the fifth day after his admission) he was found in a very prostrate con- dition, with staring eyes, and a stupid look, apparently insensible to every- thing around him, and picking the bedclothes. His skin was hot, but his pulse was not more than 64. He had an attack of syncope some time after- wards, and during the night he uttered plaintive cries without coming out of his somnolent state. The sopor was more marked the next morning, and his eyes remained half-closed without the pupils being dilated. The breath- ing was uneven, and the patient uttered plaintive cries again, as during the night. Although apparently insensible to everything around him, he felt very well when he was pinched, and withdrew his arms. The carphology persisted, the fever was more intense than on the preceding day, and yet the pulse was not more than 84 or 88. There was again very obstinate constipation, so that I ordered an enema to be given (an ounce of decoc- tion of senna leaves, and half an ounce of sulphate of soda). This produced very slight effects. On the 18th, in the morning, profound coma had suc- ceeded to the somnolence; the pulse was small, and 140 in the minute; there was left hemiplegia. On the right side sensation was still retained, for when pinched the patient withdrew his arm and leg, while on the left, pinching was not felt. The bladder was distended. Death took place at 4 a.m. We had already ascertained that two brothers of this patient had died at the same age and in the same manner. The autopsy showed the presence of encephalitis. In the posterior part of the right optic thalamus there was found an indurated mass, of a yellow color, and dotted with numerous red points (capillary hemorrhage). In the centre of this mass were other small nuclei, not larger than millet-seeds and having all the characters of tubercular matter. The cerebral tissue was softened, but not diffluent around the whole mass. The lateral ventri- cles contained about a teaspoonful of reddish serosity, and small gray gran- ulations were scattered over the meninges, which were very dry. The two layers of the pleurse adhered firmly to one another, and in the CEREBRAL FEVER. 875 substance of the lungs, which were congested, a few small tubercles were scattered. I wished to recall these cases to your memory, gentlemen, before speaking to you of cerebral fever a propos of two babies, one of whom died a few days ago, and the other only yesterday, so that I shall have an opportunity of showing you once more the characteristic lesions of this cruel and inexor- able complaint. The first of these children was a little boy ten months old. Nine weeks previously his mother had brought him to me for the first time, on account of an unhealthy-looking ulcer which he had in the neck, and which was covered with pultaceous concretions. The perpendicular and indurated edges of the ulcer, its uneven and hard bottom, and its color, had all the appearances of a scrofulous ulcer. I had it painted with tincture of iodine, and three weeks afterwards, the surface of the ulceration had been modified, a complete cure was brought about, and the baby was discharged from the Hotel-Dieu. I had, however, been struck with the patience with which the child bore the pain produced by the iodine paint, which is generally very acute when applied to a raw surface; but this baby evinced very little sen- sibility. I was surprised at this, and wondered whether something serious was not hidden under it. The cause soon became apparent, for my fears were realized in a short time. A fortnight after he had been discharged, the child was brought back, suffering from cerebral fever which was incu- bating during his first stay in the hospital. The development and evolu- tion of this fever were so regular, so classical (if I may be allowed the ex- pression), that there could be no doubt as to the nature of the case, although, in too many instances, the deceptive course of the disease misleads men of the most consummate experience. • The child's mother gave us the following statement as to the manner of invasion of the complaint. She brought the child back on a Monday; eleven days previously she had, on her own authority, given him some ipecacuanha on account of a cold in the head. The ipecacuanha brought on vomiting, which had not ceased even when I saw the child; he was strangely agitated, had no sleep, but merely dozed, rousing himself at intervals, and uttering a loud cry. These symptoms, namely, vomiting, insomnia, somnolence, with sudden awakenings and utterance of loud cries, too clearly indicated incipient brain-fever. The pulse gave no indication yet, but in another week, its inequality, and the diminution in the number of pulsations, became a new feature of the disease. Yet the child continued to take the breast. As the vomiting had ceased, one who was not forwarned might have thought that the child was better. But, independently of the signs which I have men- tioned, and which left no doubt on my mind, I already noticed that the child was singularly agitated when I came near him, but soon became calm again, and fell into a doze. This was a symptom of considerable significance; and all the others showed themselves in succession, namely, cerebral macula, dilatation of the pupils, paralysis more marked on one side of the body than on the other; lastly, convulsions, and extraordinary frequency of the pulse, which from 68 rose to 80, 100, 140, 160, up to 208 on the day preceding death. On making the autopsy, I found notable thickening of the meninges, which, about the optic commissure and in the fissure of Sylvius, were infil- trated with fibro-plastic elements and concrete albumen, while there were numerous granulations disseminated on the surface, especially over the left cerebral hemisphere. The septum lucidum was in a perfectly pulpy con- 876 CEREBRAL FEVER. ditiou ; the fornix was less softened, but tore on the least pulling, and the softening had also involved the posterior wall of the lateral ventricles. There were granulations in the lungs also, while the bronchial glands were converted into tubercular masses, and similar ones were found in the spleen. The other child, who died yesterday, and whose body I am going to examine in your presence, was a little girl eighteen months old, nursed by her own mother. Although of an apparently sound constitution, she had been seized about six weeks ago, when she was noticed to have an unusual, sad look. This could not be ascribed to the process of teething, because she had cut her first group of teeth for the last four months, and there was no indication that the evolution of the upper incisors, which were to form the second group, had commenced. Sadness setting in unaccountably, is a premonitory sign of great value in a child; it points to a condition of malaise, surprises the child's friends, makes them uneasy, and is often men- tioned by them, as it was in this case by the mother of the little girl. She added besides, that the child's sleep was not continuous, and was, as it were, disturbed ; yet a symptom which is very common at the onset of cere- bral fever was absent in this case-the child did not start out of her sleep and did not utter the peculiar cries noted in the case of the little boy which I related to you just now, and which constitute a sign of some value in the history of cerebro-meningitis. Vomiting set in a week ago : the child brought up everything that she took, panadas, her mother's milk, sugared drinks, so that her mother began to feel seriously uneasy. These fears increased three days later on account of another symptom which she described very well and which it is essential I should point out to you. The child cried whenever she was taken up, as if in great pain ; and, indeed, there was general hypercesthesia. Lastly, four days ago, convulsions came on, at first on the right, then on the left side ; and it was then that the mother came to the hospital. Let us now rapidly review the symptoms which this child presented, and compare them with one another, as well as with those which are common to brain fever and other diseases. When I first saw the child, I was struck with the motor disorders of her visual organs. There was very marked convergent strabismus of the right eye, the pupil of which was dilated, although less notably than that of the left eye: consequently, the muscles supplied by the sixth nerve must have been paralyzed. Sight seemed to be abolished on the left side, because when I held my finger in front of that eye, there was no longer the invol- untary and instinctive winking which usually occurs for the protection of the threatened eyeball. There was probably blindness, or at least, a very marked diminution of sight. More or less complete amaurosis is a symp- tom which you have noted yourselves in all our cases of brain fever, and which is complained of also by children old enough to talk and give an account of their sensations. In the little girl in question, the greater dila- tation of the pupils, the absence of all movement of the eyelids, the strabis- mus of the right eye, very clearly indicated that sight was impaired. The head was slightly pulled back also, the left arm was stiff, and was from time to time the seat of clonic movements of flexion and extension. The thumb of the left hand, forcibly adducted into the palm, was covered over by the fingers, which were like itself convulsively bent; when an attempt was made to stretch them out, they yielded with some facility. On expos- ing the child's abdomen, it was seen to be excavated-hollowed out like a boat from the sinking in of its walls. This sign is of great value in the history of cerebral fever, because it is nearly constant. In a great many CEREBRAL FEVER. 877 cases it may help to distinguish the brain-symptoms of cerebro-meningitis from those which appear secondarily in the course of other diseases, such as typhoid fever, for example. You must not think, however, that there is no chance of error when this symptom exists; its diagnostic significance, although of great value, is not always absolute, and not long ago I found among my papers notes of a case which shows how difficult it is in some cases for a medical man to decide. The subject of that case was a little girl seven years and a half old, who was under my care at the Children's Hospital, towards the close of the year 1852. She was of a lymphatic constitution, and had had for months past a cough, and some diarrhoea. She had been worse for two or three days, and had been seized with vomiting. She was delirious the night after her admission, and on the next morning she was very prostrate, al- though conscious. Her pupils were dilated, more so on the right than on the left; her belly was retracted in the manner I have described above, and was tender on pressure. Her pulse was excessively slow, 56 in the minute. (I insist on this fact, which is almost constant in brain fever.) In addition, the meningeal or cerebral macula (which I will presently describe more particularly), was easily produced, and became still more marked on the following days. She never uttered, it is true, the hydrocephalic cry, nor was her breathing unequal; but with these exceptions, all her symptoms seemed to point to cerebro-meningitis. Yet, the case was one of typhoid fever, and after death I found no changes in the brain and its meninges, while the swelling and ulceration of Peyer's patches, in the small intestines, were characteristic of typhoid fever. Dilatation of the pupils, even when it is not equal on both sides, retrac- tion of the abdominal walls, constipation (for the girl's bowels from being loose had become costive), and the cerebral macula itself, are not therefore absolute pathognomonic signs, although they are phenomena of very great value. Now, what are the characters of that cerebral or meningeal macula which I have taken care to point out to you in the above cases, and which you always see me carefully look for in individuals whom I suspect of being the subjects of cerebro-meningitis ? When, in order to ascertain how many teeth the little girl in St. Bernard Ward had cut, I opened her mouth with my hands, you must have been struck with the bright red tint which her skin immediately assumed. Again, when I very gently made on her abdo- men with my nail cross markings, longitudinally and transversely, in less than half a minute the portion of skin which I had touched was suffused with a very bright red tint, which was diffused at first, but grew by degrees fainter, leaving along the track where the nail had passed, lines of a deeper red color, which persisted for a pretty long time. This is what I mean by cerebral macula. I was the first to call attention to it more than twenty years ago, and I then called it meningeal macula. This singular phenome- non, which can only be explained by a deep modification in the vascularity of the skin, is a sign of sufficiently great importance to arrest our attention for awhile, although I repeat, it is not of absolute value when the differen- tial diagnosis of cerebral fever has to be made. The regions where the macula appears most easily are at first, and above all, the anterior aspect of the thighs, the abdomen, and the face. I have just described its characters. If after exposing the patient, his skin be gently rubbed with a hard body, such as a pencil, or simply with the nail, the part touched rapidly becomes of a bright red color, which persists for a more or less prolonged period, eight, ten, or fifteen minutes. Its ex- istence has not been denied (for it is unquestionably brought out under 878 CEREBRAL FEVER. those conditions), but the importance which I attach to it has been ques- tioned, on the ground that it was met with in other diseases than cerebral fever. I admit that this may occur, and the case which I related to you just now proves it; but whereas it is an invariable, constant phenomenon in cerebral fever, observed throughout the whole course of the disease nearly, from the beginning to the end, it only appears exceptionally and accidentally in other affections. It has been said that this mottling was always observed, when looked for, in children suffering from simple feb- ricula. But I protest against this assertion, gentlemen; and I have more than once shown you in our clinical wards young children laboring under intense fever, attending sometimes violent stomatitis, and at other times grave pulmonary catarrh, or grave pneumonia, and when I have in such cases tried to produce the mottling by rubbing the skin, and even so roughly as to scratch it, I indeed made the parts which I touched red, but the redness was never to be compared, as regards intensity and duration, with the redness produced in individuals suffering from brain fever, even by the gentlest frictions. In the latter, it persisted for a good while; and it not only involved the parts which had been directly touched, but spread also for several centimetres beyond them, while in other complaints it is ex- clusively limited to the points where it had developed itself. I lay so much stress on this point, because it is, in my opinion, of great significance in a good many cases, when the possible confusion between brain fever and other diseases has to be avoided, such as typhoid fever, attended with cere- bral phenomena or convulsions, either idiopathic, or occurring at the outset of exanthematous fevers, or grave pulmonary or other inflammations. The mottling is almost never produced in eclampsia; and when it occurs in typhoid fever, as in the instance I mentioned to you, it rarely has the same intensity and persistence, and rarely shows itself at all stages of the fever. From what I have said, it follows, therefore, that there is, properly speaking, no one invariable pathognomonic sign of cerebral fever. But in this, as in all clinical questions besides, it is not isolated symptoms, but groups of symptoms, the manner in which they appear and are evolved, and their mutual relations, which characterize the disease. We must not look at a portion of the picture only, but at the whole at once; in order to know the drama well, the whole play must be seen, and not one scene alone. Yet, in order to write the history of the disease, we are obliged to analyze its symptoms, and to make divisions with the view of facilitating descrip- tion. I will, therefore, speak of cerebral fever as having three stages, which, although they are far from being constantly present, and from being always perfectly distinct from one another, are yet sufficiently distinguish- able by certain predominating symptoms. The first of these, the premoni- tory stage, is of great importance. Killiet (of Geneva) the joint author with my esteemed colleague, Dr. Barthez, of a work on diseases of children, has laid most stress on this point, and he has recorded a pretty good number of cases which came under his own observation, and in which he was enabled to foretell the more or less immediate invasion of brain fever by means of certain signs which I am going to enumerate to you. A change in the child's manner in a great many cases, but not in all, is a sign that brain fever is imminent. This change shows itself for a more or less prolonged period, for four or six weeks, or for two, three, and more months sometimes, before the complaint actually sets in. The child is un- accountably sad, and takes less pleasure than usual in his games; his temper becomes sour, and he shows himself more irritable towards his parents, his brothers, and his companions. There is at the same time (and this is a valuable sign) marked emaciation. Sometimes there is bilious CEREBRAL FEVER. 879 vomiting which cannot be accounted for, and which recurs at more or less distant intervals. Sleep is not so profound as it used to be, and may even be replaced by complete watchfulness; in some cases this imperfect sleep is agitated, disturbed by painful dreams, by sudden starts, accompanied by those characteristic cries which become subsequently more frequent, and of which I shall speak more particularly by and by. Rilliet ascribes this series of symptoms to already existing lesions, more especially to cerebral lesions, which, although latent and assuming a chronic or, at the most, a subacute course, still exercise from that very period an injurious influence on the organic functions-those of the brain chiefly. As in children who die of brain fever tubercles are almost invariably found-not in the viscera themselves, but in the bronchial or the mesenteric, or, more rarely, in the cervical glands, it is conceivable how a tubercular affection may give rise to the general disorders which I have mentioned, and how more or less marked emaciation may result from it. As to the brain-symptoms, the change of temper, the watchfulness, or the disturbed, interrupted sleep, the cries uttered by the child, apparently indicating a sharp pain in the head, they are accounted for, according to Rilliet, by the brain-lesions which are nearly always met with when a post-mortem examination is made. These lesions consist in granulations scattered in the meninges over the surface of the brain, and in the Sylvian fissure, and which have been shown by the microscope to be of a tubercular nature. We may imagine, therefore, what an injurious influence the morbid process which precedes and accom- panies the evolution of these morbid products, however slow it may be, exercises on the functions of the central apparatus of innervation. I do not deny, gentlemen, that these premonitory symptoms occur more frequently at the outset of brain fever than of any other complaint; but one would exaggerate their import, if he were to regard them, as Rilliet has done, as characteristic of cerebral fever exclusively. They, indeed, seem to me to depend much less on an actual lesion than on the general condition which in this case passes into cerebro-meningitis, but in other cases, into latent pleurisy, or into pulmonary tuberculization, or at least into tuberculization of the bronchial glands, and in other instances, again, into tabes mesenterica, namely, tuberculization of the peritoneum and tuber- cular infiltration of the mesenteric glands. The premonitory symptoms indicate, therefore, the imminence of some disease rather than an actual disease. We know how the temper of a child changes under the influence of the least malaise, and such changes are, besides, common enough in adults, and there are very few among us who have not experienced them even in slight indispositions. They strike all the more in children, and occur all the more easily that their temper is more mobile. There is no need, therefore, in order to explain the sadness and surliness of individuals threatened with brain fever, or their unusual repugnance to join in games of children of their age, to appeal to the pres- ence of a brain-lesion, when such morbid phenomena are accounted for by the malaise resulting from the deep perturbation of the functions of the whole system, caused by the slow and fatal manifestation of the tubercular diathesis. Although these morbid phenomena may usher in other affections, it must be, nevertheless, admitted that they are never so marked as in the pro- dromic stage of cerebral fever; and there is one point concerning them to which I must particularly call your attention. You may have observed these premonitory symptoms in a child who is scrofulous, or who is the issue of phthisical parents, and have either imparted your fears to the friends, or kept them to yourself, when you see the child suddenly regain 880 CEREBRAL FEVER. his former cheerfulness and be restored to health, with the exception of some loss of flesh; then, the symptoms recur and disappear again until the day when the disease breaks out. I perfectly remember the case of a little boy whom I saw in the Tours Hospital, when I was a medical student. He was from time to time seized with fearful pains in the head, with vom- iting, somnolence, slowness of the pulse, &c. These symptoms lasted for three or four days, and on every occasion, Bretonneau diagnosed the ap- proach of cerebral fever; but the storm blew over. At last, one day the symptoms did not intermit, and we had occasion to witness all the scenes of the sad drama of tubercular cerebro-meningitis. Dissection disclosed, in addition to the ordinary lesions of brain fever, the presence of a large tubercular mass in the convolutions of the cerebellum, with softening of the surrounding tissue. It rarely happens, indeed, that in such cases the symptoms be not dependent on the presence of some organic brain-lesion, and particularly on tubercular deposit. In such cases, independently of the symptoms which I have already mentioned, intermittent cephalalgia, convulsions, and partial paralysis may supervene at more or less distant intervals, until brain fever sets in, which rapidly draws to a fatal termina- tion. Whenever, therefore, the above group of morbid phenomena are found to exist, the practitioner should be on his guard, especially if the family history of the patient points to a tubercular diathesis, because he may soon witness the characteristic phenomena of the invasion of brain fever. In general, vomiting, of an obstinate character, opens the scene; very often, this does not excite much anxiety at first; it is ascribed to a trifling indis- position, and as a moment before it set in the child seemed to enjoy his usual state of health, and ate with some appetite, it is put down to indiges- tion. This opinion is retained for a day or two; but as the vomiting per- sists and recurs frequently, alarm is excited. This symptom, namely, per- sistent vomiting, is of primary importance, and whenever it shows itself without attendant fever, in a child who has been vaccinated and who has already had exanthematous fevers, brain fever should be suspected. There is, in general, constipation also. Persistent vomiting and constipation are already two symptoms of great value. The patient complains at the same time of intense cephalalgia, which is usually general, although more acute across the forehead and sometimes at the vertex. This symptom alarms the friends most, and is the one to which they call the practitioner's attention. This headache is not by itself, however, a sufficiently characteristic sign, for there are many other diseases which set in with a more or less violent cephalalgia, pro- portionate to the intensity of the febrile reaction of which it is an epiphe- nomenon. Its persistence, however, and that of the vomiting, are all the more peculiar in cerebral fever, that the initial fever of the disease does not run the same course as in other affections. Thus, it consists of several parox- ysms, instead of a single one. The patient has two or three rigors in the course of the twenty-four hours, and after each rigor some heat of skin and perspiration ; sometimes this rigor recurs several days in succession, at the same hour; in other very rare instances, the fever is continuous but is moderate, with frequent remissions. Thus, febrile action running a pecu- liar course, violent cephalalgia, more or less limited to a portion of the head, constipation, obstinate vomiting, interrupted sleep, or complete wake- fulness, alteration of temper; such are the symptoms of the first stage of cerebral fever, to which are pretty frequently superadded singular perver- sions of sight, amblyopia, hemiopia, and strabismus. CEREBRAL FEVER. 881 I have often related the following cases, which are so interesting that they are deeply impressed on my memory. About twenty years ago I saw with my excellent friend, Dr. Pidoux, a girl, 6 years old, affected with cerebral fever. She had usually a very strange temper, and although her mother was full of kindness and indulgence for her, perhaps on that ac- count she had no caresses nor affectionate words to offer her in return. From the time when she began to complain of a pretty violent pain in the head, attended with vomiting, she insisted on always sitting in her mother's lap, kissing her repeatedly, and addressing her so tenderly, that the poor mother was deeply moved. The disease (for it was incipient cerebral fever) had gone on for three or four days, when the child, who was sitting near a window, called out, " Oh mamma! how strange! look at that little boy who is running after his hoop in the street; he has only half a blouse and half a face!" This hemiopia lasted a few minutes only; but the child's persistence and astonishment made such an impression on the mother, that she told us of the circumstance the first time we called. About ten years ago, I was sent for to see an English boy, 12 years old. He was a very good violinist, and his father, himself an eminent artist, superintended his musical studies. One day, on his playing false, and on his father complaining of it, he answered that the music was badly written, and that he only played what he saw; but as he repeated the same fault several times again, his father took the violin from him and played cor- rectly. The boy, however, asserted that he did not play the music as it was written, and reading it aloud, transposed as he did so, and changed the bars. He used at that time already to complain of headache, and the aberration of sight was the prelude of a cerebral fever which broke out a few days later, and carried him off-as this terrible and inexorable com- plaint always does. In the second stage, a delusive quiet and rest follow upon the sleeplessness, the febrile action, and the cephalalgia. The child's friends, and even the practitioner, if not on his guard, are deceived by this apparent calm and believe in an improvement which is soon shown to be unreal. An experi- enced practitioner is too well forewarned by the symptoms of the preceding stage, which have been described to him or have been observed by himself personally, to share in those illusive hopes. He is aware that the cere- bral fever has entered on its apyretic stage, and that it will run a fatal course, in spite of the apparent improvement. The pulse in this stage takes on special characters. Generally regular in the first stage of the disease (I say, generally, because it sometimes presents even at this period irregu- larities which should be taken into account) it now becomes remarkably slow, and excessively irregular and unequal. Whereas, in a child from four to five years old, the pulse normally ranges between 90 and 100 in the minute, and in an infant at the breast, between 100 and 120; it falls to 60, 55, 50, and even lower, in the second stage of cerebral fever. Somnolence contrasts with the agitation which existed at the beginning; and this apparently calm sleep, following on distressing wakefulness, at first delights the patient's friends, glad of catching at the least ray of hope; but within a short time, on seeing this sleepiness persist, alarm is justly excited. It lasts for two, four, or five days. If attempts be made to rouse the child, he utters a few impatient cries and dozes off immediately again. He is no longer alarmed now by the presence of the practitioner, whose sight he previously disliked. Formerly, he exhibited symptoms of annoy- ance when his pulse was felt, or at the least thing; but now he is indifferent to all that is done to him. His eyelids maybe separated with impunity,so as to examine the state of his pupils; and if his skin be pinched in order to VOL. I.-56 882 CEREBRAL FEVER. ascertain the degree of sensibility (which in the first stage is sometimes ex- alted, as was the case in the little child in St. Bernard Ward), he shows but momentary impatience, and immediately again lapses into his former sleepy condition. This, gentlemen, is a sign of the most serious import, which you will scarcely meet with in other diseases. Another symptom now shows itself which is per se of considerable sig- nificance. The child who in the first stage was exacting, capricious, calling for his mother and driving her away, asking every minute for food or drink, and refusing to have what he has just been asking for so pressingly, as soon as the second stage begins, no longer asks for anything, even when he is most violently agitated, and with the most distressing obstinacy keeps utter- ing the hydrocephalic cries, which I shall presently describe to you. When he is offered drink he sometimes accepts, but he never shows that he is thirsty by his gestures, or by those movements of the lips and mouth which are so characteristic in infants. He seems to have lost all instinctive sen- sations. This sort of indifference continues to the end; and even in the third stage, when there is intense thirst, he never asks for drink. If he be at the breast still, his mother must needs press him, separate his lips, and insert the nipple between them: he then sucks with avidity, or refuses entirely. This symptom is all the more important that in other febrile affections attended with brain symptoms, and which might consequently be confounded with cerebral fever, there is generally very intense thirst, which is manifested in a most striking manner. In the last stage of cerebral fever the child no longer drinks, even when liquids are poured into his mouth, not only because he has not the sensa- tion of thirst, but probably also because his pharynx and tongue are para- lyzed, as various other parts of the body are. In the space of forty-eight hours his face exhibits strange phenomena. He from time to time opens his eyes wide, which shine as they do in indi- viduals that are drunk. His face, which is usually extremely pale, blushes for a minute or two; then he closes his eyes again, and resumes his former aspect. This sort of congestion of the face, which recurs several times in the course of the day, is also of valuo. It recurs less frequently as the dis- ease progresses. Generally, as he thus opens his eyes, and as his face colors up, the child utters a sharp, plaintive cry, which is perfectly characteristic. This, the hydrocephalic cry, was first pointed out by Coindet, and it may recur every hour or half hour, at variable intervals. Although it is most frequent in infants, it is heard also in the case of adults. This cry is of such value that I must dwell more on its characters. Most frequently it is single, and loud like the cry of a person frightened by some sudden danger. I do not think that it is due to an acute pain, be- cause a child who is in pain generally utters several cries in succession, and is not consoled in a second. Besides, if the cry be indicative of an- guish, the expression of the face is rarely that of suffering. In the majority of instances the hydrocephalic cry is uttered in the second or apyretic stage of the disease, but it is pretty frequently heard at the out- set and before the invasion of the complaint even; in other words, it may constitute one of the premonitory symptoms. In some cases, again, it is only uttered in the third stage; as in the case of a little girl whom I saw, at the end of August, 1861, in the department of Maine-et-Loire, with Drs. Desperiere (of Saumur) and Duclos (of Tours), and who, during the first two stages of cerebral fever, had not uttered the characteristic cry, while in the third stage her friends were distressed by the violence and frequency of her cries. CEREBRAL FEVER. 883 A practitioner need not have been very long in practice in order to have met with cases in which the hydrocephalic cry is heard from the very begin- ning, and does not cease, even for five minutes, during four, six, eight, or ten days. In such cases, which are the most dreadful form of the disease, and the most distressing to the friends, the poor little patient never sleeps for a moment, but tosses himself to the right and left, rolling in his bed, and not soothed by caresses nor quieted by threats ; and one feels surprised that such a frail organization can resist such a prodigious and incessant agitation. It is a strange circumstance, however, that although the prog- ress of the disease is usually a little more rapid in this form, yet the pa- tient sometimes calms down, and from that time the disease runs the same course as in the simplest forms. Besides the signs gathered from an observation of the patient's face and the hydrocephalic cry, there is another sign to which your attention should be particularly called, namely, retraction of the abdominal parietes. The abdomen is excavated, hollowed out like a boat, although not tender on pressure. Although I attach much importance to this symptom, partic- ularly as it helps to distinguish cerebral fever from typhoid fever, in which latter the abdomen is usually prominent, you must bear in mind what I told you at the beginning of this lecture, namely, that retraction of the abdominal parietes is not a pathognomonic symptom. Another phenomenon which deserves more serious consideration, and which must have struck those of you who looked for it, is irregularity of the respiration. It was present in the little girl who was in St. Bernard Ward, although it was much less marked in her case than in a great many others which have come under my observation. At times it was very dif- ficult to follow the movements of the chest, when counting the breathing with a watch in hand. First came a feeble inspiration, before a small ex- piration, then a deeper inspiration with a more prolonged expiration, and next a weaker respiratory movement, and another still weaker, followed at last by a pause. These four respiratory movements were quickly perform- ed ; the chest then remained motionless for three, four, five, or six seconds. This observation was made one day, but on the ensuing days the pause lasted ten, twelve, and even fifteen seconds, instead of only from three to six. In a child of two years old, who was once under my care in the Necker Hospital, I noted, watch in hand, intervals of rest lasting from thirty to thirty-five, forty, and even fifty-seven seconds. This irregularity of the respiration occurs independently of the slowness of the circulation which characterizes this second stage, for it continues in the third stage, while the pulse then becomes extremely frequent. You will meet with this singular anomaly in no other complaint; neither in idiopathic convul- sions of infants nor in typhoid fever. I am right, therefore, in attaching considerable importance to this symptom, which is of greater value than all others in making a differential diagnosis between typhoid fever with brain-symptoms and cerebro-meningitis. Thus, in typhoid fever there may be as violent and as localized a headache as in cerebral fever; vomiting may be as obstinate; the ordinary diarrhoea may be replaced by obstinate constipation; the swelling of the spleen, epistaxis, rose-spots, and sudamina may be absent; the abdomen may be boat-shaped instead of being tym- panitic ; the cerebral macula may be developed, although in a less marked manner, but yet sufficiently to raise a doubt; lastly the pain in the head may be so acute as to cause the patient to utter cries which may be mis- taken for the hydrocephalic cry. But it is in cerebral fever alone that the respiration presents the inequality and irregularity to which I have called your attention. This symptom, which is, so to say, pathognomonic, 884 CEREBRAL FEVER. is all the more important, that the prognosis in typhoid fever is considera- bly different from the prognosis in cerebral fever, in the case of children at least. For you are aware that typhoid fever, even when complicated with brain-symptoms, is a much less grave complaint in childhood than in youth and in adult age. The same does not apply to cerebral fever, which is nearly always, not to say invariably, fatal. In the course of my medi- cal career, which has already extended over a long period, I have known two cases only terminate favorably. One of these occurred in my wards in the Children's Hospital, and I had an opportunity of verifying my diagnosis some time afterwards by a post-mortem examination. The child got well of his acute disease, which left paralysis behind it, however, but he died of dysentery five months afterwards. Dissection disclosed the most unmistakable traces of the former cerebral affection. The other case was that of a child whom I saw at Boulogne-pres-Paris, in consultation with Dr. Blache. These two instances are the only ones which I have known, I repeat, in my lengthened career, of this complaint terminating favorably; and when to such exceptional cases so very many others may be opposed which ter- minate in death, it may well be laid down as a law that this complaint is almost always incurable. This statement will perhaps be regarded as ex- aggerated, and you have doubtless heard parents say that they had children who had been cured of brain fever; and perhaps you have even heard prac- titioners boast of having mastered a disease said to be incurable, while others, as experienced and skilful as themselves, confess that they have always failed. The reason of this is that the former men mistook for cere- bro-meningitis typhoid fever complicated with brain-symptoms, which gets well in most cases. But to return to the description of cerebral fever. The third stage is chiefly characterized by the return offerer. I have said, that in the begin- ning fever came on in paroxysms of short duration, recurring three or four times in the course of the twenty-four hours, and that although it was occa- sionally continuous with frequent remissions, it was never very high. In the second stage the pulse, as we have seen, becomes remarkably slow ; but in the third stage it becomes extremely frequent, and goes on increasingly so until death closes the scene. The stupor grows more and more profound. It was already difficult, in the second stage, to rouse the child, who exhibited impatience by his grunts and cries, but who answered still the questions that were put to him ; but in this stage no sign of intelligence can be got from him, and the most powerful irritation can scarcely rouse him. The stupor is much more pro- found than that of the gravest forms of typhoid fever, for in the latter, there is usually marked agitation coexisting with other signs of ataxy, there is mussitation, carphology, and delirium, sometimes quiet and sometimes noisy. In the third stage of cerebral fever, although the patient's aspect does not, at first sight, very notably differ from that of an individual labor- ing under typhoid fever, the prostration which exists indicates a much deeper organic lesion of the brain. Delirium is at this period very rare, but it is sometimes present in the first and second stages, although it is very rare even then. Sometimes, but rarely (especially if the child be above four years old), convulsions may occur in the first stage of cerebral fever, but they do not show themselves in the second or apyretic period, or they assume at least a different form, and resemble then epileptic vertigo. The patient opens his eyes suddenly and stares fixedly; but this partial, con- vulsive movement shows itself more in the third stage simultaneously with symptoms of paralysis. CEREBRAL FEVER. 885 Strabismus is occasionally noted at the onset of cerebral fever, and as it pretty commonly occurs, together with convulsions, it may be ascribed to spasm of some of the motor muscles of the eye. But the squint which appears, and pretty frequently continues towards the close of the second stage, and nearly always in the course of the third, is owing to paralysis, because there is evident palsy of other muscles supplied by the third or sixth pair. The third nerve is the one most commonly affected ; the pa- tient opens one eye less than the other, from the levator palpebrse on that side having lost some power. Strabismus and dilatation of the pupils (which precedes and accompanies the strabismus), and the diminished power in raising the upper lid, are not the only signs of paralysis, for other regions of the body are also affected. Thus, if while the child is lying on his back, the soles of his feet be tickled one after the other, it is found that he withdraws one leg more powerfully than the other. Mobility is, there- fore, impaired on one side, and sensibility is affected as well on that side, because the child apparently feels any irritation of the skin there only when it is considerable and prolonged. - The persons about him also notice that he has greater difficulty in lifting one arm than the other, and that he lets it drop alongside of his body ; on testing it, sensibility in that arm is also found to be diminished. The paralysis which occurs in cerebral fever presents this remarkable feature, that it seems to shift about from one hour to the other. One day, for instance, the right leg is found to be drawn up with greater energy than the left, when the sole of the right foot is tickled, but on repeating the ex- amination a few days afterwards, you are surprised to find that it is the left leg which now feels and moves better than the right. It would seem from this, as if the paralysis had shifted from one side to the other ; but such is not the case : the limb which was first palsied is still so, but the illusion arises from the circumstance that, the palsy has not increased in degree in the first limb, while the second limb has become involved to a greater degree. Motor power has not returned in the former, but has been more gravely impaired in the latter. The lesions which are found after death subsequently account for these facts. When the right limbs alone were paralyzed, the brain is found to be disorganized on the left side; but when the paralysis apparently shifted from one side to the other, both hemi- spheres are found diseased, but more deeply and more extensively on the opposite side to that of the limbs which were most palsied. This apparent mobility of paralytic symptoms more frequently occurs in cerebral fever than in any other complaint. In this stage there pretty often occurs, as in grave fevers, particularly in typhoid fever, serious inflammation of the eye and ulceration of the cornea, from the absence of winking. Sensibility being either abolished or deeply impaired, and the muscles of the eyelids moving imperfectly only, the lids remain half opened, so that the conjunctiva gets inflamed and becomes the seat of a considerable sanguineous suffusion: the cornea being constantly exposed to the air, and being no longer moistened by the tears, becomes dry, ulcerates, and is at last perforated. This last accident rarely occurs, but there is, in nearly every case, congestion of the conjunctiva and pretty abundant secretion of mucus. Convulsions, which are rare in the first stage of the disease, and in the second assume the form of epileptic vertigo, show themselves again in the third stage, and constitute an important feature of it. They are sometimes inward convulsions, and sometimes consist of regular eclamptic seizures. Thus the child's face is seen to be contorted at times, his eyes roll upwards and inwards, and are the seat of slight oscillations, and his jaw moves as if he were chewing. The thumb is turned into the 886 CEREBRAL FEVER. palm, and the fingers fixed over it; and then perfect relaxation follows on these contractions. These convulsions, which are almost exclusively tonic, sometimes recur for hours together, and affect not only the limbs and face, but the muscles of the larynx also and the diaphragm, impeding respiration to a considerable degree. In proportion as the complaint draws to a fatal termination, the convul- sions become general and assume the form of grave eclamptic seizures. They recur every hour or every half hour, and even oftener, and it is after one of these attacks generally that the child dies in a state of semi-asphyxia. In other cases, death supervenes during profound coma, and trembling of the limbs, subsultus tendinum, and carphology are the closing symptoms of a more or less prolonged agony. It very often happens, gentlemen, that an arrest takes place in this fearful development of symptoms, and that the patient who, for several hours or days, was in such a condition that death was thought to be impending, seems suddenly to return to life. He wakes up from his stupor, recognizes, or seems to recognize, the persons around him, answers their questions and converses with them ; and one. must have a sad experience of this complaint in order not to share the hopes which this gleam of improvement excites in a poor mother's heart; and the practitioner must needs have great courage to moderate that joy which he cannot share, and which, in a few hours, will be replaced by so cruel a grief. How often, gentlemen, have I been received with cries of joy by happy friends, but how often also have I been compelled to meet such transports with words expressing my gloomy presentiments! Yet I must confess that, at the beginning of my medical career, I could not help entertaining hopes myself, in presence of such an extraordinary improvement. What shall I say now, gentlemen, as to the treatment of a complaint which involves such a fatally grave prognosis? Many remedies have been used against it, and I have tried them myself, but have failed with all of them; and in the two instances of cure which I mentioned to you as being too rare and too exceptional for modifying the general rule, the credit is due to nature and not to art. Purgatives, calomel in large doses, or in divided doses according to Law's method, iodide of potassium (which Dr. Otterburg states he has used with good effect), large blisters over the shaven scalp, cold affusions, ice constantly applied to the head, have all been tried by me, and always without success. Next, by instituting a comparison between the results of energetic treat- ment, and those of the expectant method, I found that death came on at an earlier date in the first class of cases than in the second. Yet, however convinced I may be of my powerlessness, I cannot decide on remaining perfectly passive, and although taught by a long experience that my efforts will be unsuccessful, I still try to struggle, and by so doing I, at least, do not crush all hope in the patient's friends. I keep up their courage, and do not cause them to regret afterwards that they did not try to save the child. Put, convinced as I am also that too active a treatment more promptly exhausts the vital energy, I try to do the least possible harm, since I can do no good. Calomel, in very small doses, and given more with the view of purging than as an alterative, musk suspended in syrupus setheris, and antispas- modics, are the simple remedies to which I have now recourse when I am free to act. I feed the patient at the same time, and I regard light feeding as the best means of prolonging his life a little more. When after death the nature of the anatomical lesions of cerebral fever is CEREBRAL FEVER. 887 determined, the inexorable gravity of the prognosis becomes intelligible, as well as the powerlessness of the practitioner. Here is, gentlemen, the brain of the child who gave rise to this lecture. At the base, on a level with and behind the optic commissure, the meninges are thickened and infiltrated with a purulent fibro-plastic material. The infiltration does not in this case extend to the fissures, between the cerebral lobes, where it usually is very marked ; and, as happens in some rare cases, there is no tubercular matter to be seen, either accumulated in masses or scattered here and there, nor are there any gray, transparent granulations, of variable size, but generally not larger than grains of semola. On making incisions through this brain, we come to the lateral ventricles, which contain some rather turbid serosity. The great nervous centres, the fornix, septum lucidum, corpus callosum, and floor of the ventricles are perfectly softened; the cerebral mass is reduced to a pulpy condition. In the lungs, which you see here, there are no traces of tubercles, nor are there any in the bronchial glands; the mesenteric glands were not tu- bercular either. On this point, this case is an exception to the rule, for of thirty children who die of cerebral fever, dissection reveals the presence of tubercular deposits in twenty-nine. This case seems to me to prove once again that cerebral fever, when said to be idiopathic, that is, occurring in individuals that are not tubercular, does not run a different course from the one it affects in tubercular persons. The prodromata alone differ; one may conceive how the more or less rapid development of granulations and tubercular masses in the meninges gives rise to peculiar symptoms which constitute the prodromic stage of cerebral fever; just as the development of granulations in the peritoneum or the pleura is accompanied by peculiar symptoms. But when acute pleurisy or peritonitis sets in, the presence of these granulations has no influence on the symptoms of the first stage of the disease, and will only influence its ter- mination. It must be added, however, that the presence of granulations and tubercles in the meninges, is such a powerful cause of congestive flux to the brain, that the children must sooner or later die of inflammation. I reject the name of meningitis for cerebral fever, because the lesions of the meninges seem to me to be secondary only, and much inferior in impor- tance to the deep anatomical alterations seated in the brain itself, such as the softening which destroys the fornix, the septum lucidum, the corpus callosum, thalami optici, and posterior part of the cerebral lobes, to a more or less considerable extent. Hence, if the disease should be named after the organic lesions which characterize it, it ought to be called cerebro-men- ingitis. Chronic Hydrocephalus. The cerebro-meningitis of which I have just now' spoken, differs greatly from and is never the starting-point of what is called chronic hydrocephalus, an affection of which you may now see an instance in a young child in St. Bernard Ward. The first thing which strikes an observer, w'hen he looks at a hydroce- phalic individual, is the enormous size of the head, out of all proportion with the rest of the body. You have seen the child in the ward: when he was admitted, the circumerence of his skull measured 50 centimetres (20 inches) on a level with a line drawn a little above the eyebrows. Cases have been recorded, and I have brought here from the anatomical museum of our faculty, this head, which you may see, and which measures 1 metre (40 inches) round its circumference. On opening it, it was found to con- 888 CEREBRAL FEVER. tain within its ventricles, 30 lbs. of fluid and more. Frank mentions a case in which the fluid effused amounted to 50 lbs.; in another case, the circum- ference of the skull measured 52 inches. You have observed the peculiar deformity of the head of the child in my wards, and although it is not exaggerated in his case, it still gives you an idea of what it may be in hydrocephalus. There is, first, a considerable disproportion between the face and the skull, the former looking excessively small, for the very reason that the latter is enormously developed, and be- cause also the frontal bones project enormously forwards on a level with the superciliary arches, so that the orbits are pushed down, as it were, and the vertical diameter of the face is, therefore, diminished. This disposition, according to Camper, suffices to enable one to recognize hydrocephalus. Moreover, the two frontal bones separate from one another, from their median suture, which is incompletely united in a child, widening more or less. The same obtains with the sagittal and lambdoidal sutures, the two parietal bones separating from one another and from the occipital bone, which, like themselves, is pushed outwards. The cranial bones are, there- fore, soldered together at the base only and fall back (if I may be allowed the comparison) like the petals of an opening flower. On looking at the patient's head, one might think that it was soft, for, when it is moved, un- dulations are noticed at its upper part, and these are again produced when the child cries or draws in a deep breath. The upper part of the head ex- pands, and is raised during forced expiration, but not during inspiration. By applying the hand over this deformed skull, the separation of the bones may be detected, and this is particularly marked about the fontanelles. The interval between the parietal bones and between the latter and the twTo frontal bones, may sometimes measure 15, 20, 30 centimetres (6, 8, 12 inches), and even more. Over those parts, the cranial cavity is merely closed by a soft membrane, the pericranium. In some cases, small wormian bones are found in these membranous spaces, in variable numbers. (There is one of these at the posterior part of the sagittal suture, in the child in St. Bernard Ward.) Hydrocephalus may last for a long time, especially when it tends to- wards a cure (a very rare mode of termination). It may be stationary at least for four, five, six, and ten years, as in cases on record, and even more; for individuals who were afflicted with this complaint almost from birth, have been known to live to a very advanced age. Frank relates the history of two men, one 72 years of age, and the other 78, who were hydro- cephalic from birth. In such cases, the wormian bones increase in number, and becomes centres of a process of ossification by which bony causewTays are, as it were, formed between one bone and another, indicating a ten- dency to union, which is always incomplete, however. This enormous en- largement of the skull can only be accomplished, as you may conceive, by distending the skin; hence, after a certain time, from the integuments yielding less easily, the distension takes place at the expense of the con- tiguous parts, namely, of the face, and, especially, at the expense of the skin of the eyelids. The physiognomy of the patient henceforward assumes a peculiar and extraordinary aspect. The eyebrows are pulled upwards, so that the projection of the upper ridge of the orbit which they previously concealed is left exposed; while the upper lid, in consequence of the same traction, becomes too short to cover the eyeball, which seems to project, and to look down and towards the lower lid. In nearly every instance, there is then weakness of sight, or even complete blindness; and, as in con- genital blindness, the eyes (which, in hydrocephalus, remain bright and CEREBRAL FEVER. 889 clear) do not gaze at anything, and are the seat of nearly incessant oscilla- tions. The patient looks sad, but he generally has no pain. Commonly also, the general health seems to be triflingly disturbed; the child, if at the breast, takes it easily, and al] his functions are performed regularly. In a certain number of cases, however, hydrocephalus is pretty frequently accompanied, at the outset, by convulsive phenomena. This was the case in the child in St. Bernard Ward. When only three weeks old, and there- fore almost at birth, he was seized with convulsions, which recurred from four to six, eight, ten, and even twenty times in the course of twenty-four hours. Three months ago, his mother brought him to me for the first time on account of those convulsions, the cause of which I could not make out, for nothing could make me suspect hydrocephalus, as the head was then of normal size. Eclampsia may, therefore, be the only symptom announc- ing the invasion of the disease, and it is caused by the sub-inflammatory condition of the serous lining of the cerebral ventricles, which condition also brings on the serous effusion which is poured out into those cavities. The frequent recurrence of convulsions for some length of time should even cause a medical man to suspect the possible supervention of hydrocephalus. In the case of the child, at present in the ward, the convulsive seizures recurred for two months and a half before the head began to enlarge. These convulsions generally increase in violence by degrees, and it very frequently happens that when they have lasted for a certain time, the patient is carried off by an attack of cerebral fever, and the lesions of cerebro-meningitis are then found, on dissection. When hydrocephalic individuals die of some intercurrent affection, and an opportunity is thus afforded of examining their heads, the ventricles of the brain are found to be enormously enlarged ; the brain, the convolutions of which are flattened, is generally sound at the base, but the convolutions of its upper surface are completely effaced and not recognizable from the sulci which have disappeared, and the organ is reduced to a kind of lamina, which the unassisted eye can scarcely recognize as cerebral tissue, the ele- ments of which are, however, made out by the microscope. The mem- branes themselves (pia mater, arachnoid, and dura mater) participate in this thinning, and you may imagine how considerable it must be in those cases in which the fluid effused amounts to 30 and 50 lbs. Although hydrocephalus almost invariably terminates in death, it may, however, progress very slowly, and I mentioned to you just now, instances of individuals who lived four, five, ten, and even (as in cases recorded by Frank) seventy-two and seventy-eight years. Apart from these exceptional cases, which are not, however, very rare, this complaint lasts habitually a year or two, unless it presented acute symptoms from the beginning, in which case death sets in rapidly. But how lamentable the life to which the unhappy individuals, whose existence is prolonged, are condemned! What a sad spectacle to those around them! and what a source of con- tinual affliction they are to their parents! So long as they are infants in arms, they can scarcely bear the weight of their head : by and by, when they begin to walk (and they always walk later than other children), their gait is vacillating, and as the disease progresses, they can no longer stand, and are confined to their beds. Several reasons concur in causing this inability to stand or to sit up. There is, on the one hand, the enormous weight of the head, which is no longer balanced on the trunk ; and on the other, blindness, which accom- panies hydrocephalus, and which, by rendering the patient incapable of guiding himself, prevents his walking; and lastly, there is a kind of paral- 890 CEREBRAL FEVER. ysis, resulting from the compression of the nervous centre. I say a kind of paralysis, because the paralysis is not carried to the degree which might have been, perhaps, expected. In the case of the child at present in our wards, although the amount of fluid poured out into the ventricles must be considerable, if wfe estimate it by the size of the head, there is no symptom of paralysis; the child moves his legs and arms easily, and his bladder freely expels the urine. The reason of this is, that the skull has yielded to the pressure from within, and, as a consequence of its enlargement, the brain has escaped compression. But when hydrocephalus has reached such a degree that the skull can no longer expand, there comes a time when compression is unavoidable, and the functions of the organ being abolished, loss of motility results. Even when the disease is stationary for a very long period, there is arrest of mental development; the intellect fails, and this failure generally passes into nearly complete imbecility. In all these cases, therefore, prognosis is of the most serious character, and medicine is always powerless to cure or even to relieve the sufferer. Yet there has been no lack of methods of treatment. With the view of combating the subacute inflammation which causes the effusion, purga- tives, calomel, and even bloodletting, have been recommended ; diuretics, sudorifics, and sialagogues have been vaunted. Methodical compression of the head has been particularly lauded, and I long had recourse to it myself; but I have now completely set it aside, on account of a case which fell under my notice. I was once consulted about a child, five months old, who was suffering from chronic hydrocephalus, and whose head was of about the same size as that of the child in the ward. I had hopes that, by compressing the head by means of strips of sticking-plaster, I might prevent a further increase of the effusion: at the end of a week, I went to see the child, and to apply fresh strips of plaster, after removing the old ones. The size of the head had appreciably diminished, but the child died suddenly, five or six weeks after the second application of the compressing plaster. He had suddenly cried out as he was going to take the breast, a copious flow of liquid had taken place through the nostrils, and the head had shrunk like a bladder which empties itself. Now, what had occurred ? As the compression of the upper part of the .cranium prevented a further effusion of liquid, the base of the skull had yielded, as it does when, in order to separate the cranial bones, anatomists fill it with water and haricot beans, which latter, on swelling, disarticulate the bones. In the case of my young patient, the base of the skull had yielded to the pressure of the fluid, disarticulation had occurred, and the fluid, finding a channel through the ethmoid bone, had flowed out through the nasal fossae. Death had then resulted from the sudden change which had taken place in the anatomical conditions of the brain. The brain has been tapped through the sutures and fontanelles by cele- brated surgeons, and the operation has been even repeated several times on the same individual; but many of those who had praised it at first have finally proscribed it, for its advantages do not counterbalance its disad- vantages. Of late, iodide of potassium has been very much lauded ; and for the last few years, I have myself used iodine lotions to the head. I give iodide of potassium internally at the same time, in doses of two grains at first, which I gradually increase to four, five, six, and even eight grains, according as it is tolerated. The end which I have in view by prescribing iodine lotions is to favor the absorption of the effused fluid, guiding myself on the success obtained by means of these lotions, in effu- sions into the serous membranes of the pleura, the abdomen, or the joints. CROSS-PARALYSIS, OR ALTERNATE HEMIPLEGIA. 891 LECTURE XLIX. CROSS - PARALYSIS OR ALTERNATE HEMIPLEGIA. In most Cases it is owing to a Lesion of the Pons Varolii, but it is not an Ab- solute Sign of suck Lesion. It should not be Confounded with Glosso- Laryngeal Paralysis. Gentlemen: When an individual is struck down with hemiplegia, the paralysis affects the limbs and the face on the same side. There are, how- ever, exceptions to this general rule; and for those rare cases in which the face is paralyzed on one side, and the limbs on the opposite side, Dr. Gubler has proposed the name of alternate hemiplegia. Very recently, in September, 1861, I saw, in consultation with my col- league and friend, Dr. Hillairet, a little girl from Clermont-Ferrand, seven years old, who had met with a severe fall backwards a few months pre- viously, and had knocked the back of her head and the upper part of her neck against a piece of furniture. She complained almost immediately of heaviness of the head and of feeling drowsy, but after a few days she felt well again. Shortly afterwards, however, she complained of a pain both in the occiput and the forehead. Her friends noticed also that she hesitated in her gait, and that she had grown irritable and made grimaces. Three months after the occurrence of the accident, there was found weak- ness in the whole left side of the body, as well as a very marked paralysis of the right side of the face. She was then sent to Paris by Dr. Bourgard, and on our seeing her we thought that the pons Varolii and the upper part of the medulla oblongata were injured, and we gave an unfavorable prognosis. We lost sight of the patient, so that we could not verify the accuracy of our diagnosis; but we thought we could make it in this instance, on the ground of its analogy to the cases recorded by Dr. Gubler, showing the relations which generally exist between cross-paralysis and injuries to the pons Varolii. The body of a woman, however, who died at No. 6 in St. Bernard Ward, of some cerebral affection which had produced cross-paralysis, was exam- ined, after death, in your presence. But the results of the autopsy disap- pointed us, and seemed in contradiction to the law laid down by my learned colleague of the Beaujon Hospital. The patient was a servant thirty years of age. She was admitted into the Hotel-Dieu for a violent pain in the head, which only dated a few days back, and was not localized in any one spot more than another. She was not feverish, her appetite was good, and she complained of nothing else but the headache. Her menses had come on a few hours before admission, and she stated that she was usually liable to this pain in the head at her men- strual periods. The next day, by the time I went round the wards, nothing fresh had occurred to call for my attention; yet, although the patient gave clear an- swers to the questions put to her, I noticed that she labored under a certain amount of hebetude, of mental languor, which could be after all accounted for by the cephalalgia. 892 CROSS-PARALYSIS, OR ALTERNATE HEMIPLEGIA. The absence of all febrile symptoms, the good condition of her functions in general, did not call for active medical interference; and I had decided on waiting before adopting any treatment, when fresh symptoms manifested themselves during the day, which towards evening alarmed my clinical assistant. The patient had been suddenly paralyzed. There was incom- plete motor paralysis of the right arm and leg, while tactile sensibility was preserved. When the palsied limbs were pinched or merely tickled, the patient drew them away, although less easily and less quickly than she withdrew her left arm and leg under the same circumstances. The head was inclined to the left and the face turned to the right, from the contrac- tion of the left sterno-cleido-mastoid, whilst the analogous muscle on the right side was relaxed. There was hemiplegia, therefore, but the paralysis, while involving the right limbs and the right half of the trunk, affected the left side of the face. The face wore a singular expression, and was dragged to the right, that is, to the same side as the paralysis of the limbs. The mouth was distorted, the labial commissure on that side was higher than the other, whilst fhe left cheek was more flaccid than the right. Moreover, the patient, who gave distinct answers to questions put to her, stated that she could not see with her right eye, whilst on the left side her sight was good ; both pupils were equally contracted. The paralysis of the left side of the face, which coincided with the diminution of sight on the right side, was evidently less marked than the paralysis of the limbs. The pain in the head was as violent as ever, and there was no fever. The patient asked for food, although her tongue had a yellowish coating of fur. An emetic was ordered, but on the following morning the symp- toms had become more marked. Motion was more impeded and sensation duller than on the preceding day. The paralysis of the face, although less marked than that of the limbs, had increased, although it was not so marked as in cases where it is due to a lesion of the seventh pair exclusively. The intellect was impaired, and although the patient was awake, and seemed to hear when she was spoken to, she no longer answered. Death took place at 4 o'clock the next morning. A post-mortem examination was made about thirty hours afterwards. On removing the calvarium, a pretty considerable quantity of black blood escaped from the gorged vessels of the pia mater over the whole surface of the hemispheres. The congestion was most marked at the base of the brain, and there was found in the interpeduncular space a black mass, consisting not only of vessels distended with blood, but of extravasated blood also, which was in part liquid, and in part coagulated, and had made its way into the fissure of Bichat. The nerves of the seventh pair exhibited no alteration at their superficial origin, behind the pons Varolii, although the right nerve seemed to tear more easily than the other. Independently of the meningeal hemorrhage, the brain was softened in its central parts, on the left especially, where the corpus callosum, the fornix, and the septum lucidum were broken down when a small stream of water was poured upon them. There was no effusion into the interior of the ventricles; and, lastly, the pons Varolii presented no lesion, either on its surface or more deeply; on making numerous sections through it, no tumor was found, nor traces of hemorrhage or of softening. The results of this examination, then, as I have told you already, are in contradiction to what Dr. Gabler has taught us on the relations between alternate hemiplegia and lesions of the pons. For in this case-which was, it is true, anomalous (since the phenomena observed during life did not correspond regularly with the organic alterations found after death)-the pons presented no appreciable sign of disease, however carefully we CROSS-PARALYSIS, OR ALTERNATE HEMIPLEGIA. 893 examined it. As no such lesions were found, it has been doubted by some that there had been cross-paralysis; and it has been asked whether I had not made a mistake as to the side of the face which was paralyzed, and whether I had not mistaken contraction of the muscles of the right side of the face for paralysis of the left side. The objection, I admit, was all the more founded that the softening of the right facial nerve did not harmonize with the retention of motor power on the corresponding side of the face-. But my answer is, that however obscure and inexplicable the facts may be, I have no doubt in my own mind that the case was not one of contraction of the right side, but of left facial paralysis (the left cheek being more flaccid than the right), and that this coincided with paralysis of the right limbs; lastly, that whatever the other lesions of the brain might be, the pons Varolii showed no trace of disease. Although I admit that a rigorous conclusion cannot be drawn from an exceptional case, full of anomalies and of obscurity, it would yet seem that the law laid down by Dr. Gubler is not so absolute as he has asserted. Those among you who have read the two interesting memoirs which he has published on this subject,* know that he regards cross-paralysis as a sign of disease of the pons; and, localizing still more specially the seat of the anatomical change, he places it in the bulbous portion of the pons. Hence, this particular form of hemiplegia is, according to him, explained in the following manner: As the lesion involves the facial nerve after its decus- sation, the face is paralyzed directly, while the parts that are supplied by nerves from the spinal cord are paralyzed in a crucial manner, the decussa- tion of the anterior pyramids taking place below the pons only. I am far from denying the value of the reasons urged by Dr. Gubler in support of his position. The cases which he brings forward, and discusses with great talent, are sufficiently imposing in number and of undoubted value; but yet I cannot refrain from thinking that the law which he has laid down is too absolute. Setting aside the case of the woman in St. Ber- nard Ward, I shall find in Dr. Gubler's memoirs themselves arguments in favor of my opinion; for when he comes to the differential diagnosis of cross-paralysis, and what he terms false cross-paralysis (namely, cases in which there is more than one cerebral lesion), Dr. Gubler meets with embarrassing cases, which he tries to explain by hypotheses which cannot be demonstrated. Such, for instance, are Cases XII and XVI of his second memoir. In both of these the paralysis involved the right side of the face and the left limbs, and had set in after a ligature had been put round the right common carotid artery. The first of these cases was pub- lished by Professor Sedillot, of Strasburg, in the "Gazette Medicale de Paris," for September 3, 1842. A post-mortem examination disclosed softening of the right hemisphere of the brain, while the pons is not men- tioned. Dr. Gubler analyses these cases, and justly rejects the explanation of the facial paralysis given by Professor Sedillot-namely, that it was owing to the facial nerves supplying directly the side of the face correspond- ing to that of their origin. Although the decussation of the nerves of the seventh pair is not regarded as proved by all anatomists, since M. Sappey has never been able to see it, in spite of the most minute dissections, the fact is admitted, and has been ascertained by Professor Jobert (de Lam- balle), by Messrs. Vulpian and Philippeaux, and by Stilling, although the last three state that the decussation is not complete. Besides, the fact that * " De alterne envisagee comme signe de lesion de la protuberance annulaire," &c. (Gaz. Hebd. de Med. et de Chir., Paris, 1856), et " Memoire sur les Hemiplegies alternes," (in idem, 1859). 894 CROSS-PARALYSIS, OR ALTERNATE HEMIPLEGIA. in most cases, paralysis of cerebral origin affects the face and limbs on the same side, tends to prove the existence of a decussation. But if Professor Sedillot's interpretation be faulty, Dr. Gubler's may also raise objections. The arrest of the flow of blood consequent on ligaturing the common carotid is not, to my mind, sufficient to explain, as my colleague thinks, the impair- ment of motion and sensation which occurred in the corresponding side of the face. No one surely denies the existence of paralysis, or rather of varieties of paralysis, due to an arrest of the arterial or venous circulation; but such paralysis is seen in the limbs only, not in the face, in which there are large and numerous anastomoses between the divisions of the two carotid arteries, which easily permit of a supplementary circulation. The second case is that of an individual in whom both common carotid arteries were ligatured successively, at an interval of twenty-eight years, for a circoid aneurism of the head. The first ligature was placed round the right common carotid by Dupuytren, and no accident followed ; the second time, the left artery was tied by M. Robert. "The result of the operation was as satisfactory as possible; there was some mental excite- ment only, and the patient insisting on returning home, he had to be dis- charged two or three days afterwards. The joy he felt at finding himself again among his friends produced still greater exaltation, and brought on delirium, which was soon followed by well-characterized paralysis of the right half of the face and the left side of the body. Death took place shortly afterwards, and a post-mortem examination could not be made." In this case Dr. Gubler does not explain the facial paralysis by the de- fective circulation resulting from the obliteration of the artery, as the paralysis involved the opposite side of the face to that on which the artery was tied ; but in order to make the facts fit in with his theory, he says: "After the right common carotid had been tied, the circulation of the blood was re-established in the corresponding hemisphere, through the carotid of the opposite side, by means of the communicating artery of Willis, and through the vertebral of the same side, which necessarily in- creased in size from the innominate retaining its capacity and from the ex- pansive force of the blood-current, which no longer found a wide passage through the carotid, tending of necessity to dilate the vertebral and the subclavian. Now, it may be presumed that the vertebral could not be thus distended without its walls being at the same time altered, or the walls of the basilar, which is its continuation. This is all the more probable that aneurismal dilatation, or at least atheromatous and calcareous changes of the coats of these vessels, are of more frequent occurrence than of other in- tracranial arteries. The nutrition of the substance of the brain had, perhaps, also undergone some modification, which rendered the organ more liable to become the seat of hemorrhage. The left carotid being tied under these circumstances, the blood can only flow through the two vertebral arteries, the walls of which are therefore subjected to a relatively enormous pressure. The left vessel, which has healthy coats, resists successfully; whereas the right ruptures, the rupture involving either the trunk of the artery, or one of its branches, on the surface or in the substance of the right half of the pons near the medulla oblongata. The inevitable result of this, in our opinion, is paralysis of the right half of the face, and of the upper and lower limbs on the left side." You see, gentlemen, that however ingenious these explanations may be, they are merely conjectures; and that, instead of drawing his conclusions from observation, Dr. Gubler makes observation fit in with his views. Of course those cases alone are in question in which the cross-paralysis of the face and limbs is due to one lesion only, for it is conceivable (and FACIAL PARALYSIS, OR BELL'S PARALYSIS. 895 Dr. Gubler has called attention to the fact) that cross-paralysis may be caused by several lesions affecting different parts of the brain-a hemi- sphere on one side, and the facial nerve on the opposite side. But Dr. Gubler does not apply the term "cross-paralysis" to such cases, and con- fines it to those in which there is a single lesion. But although I do justice to my colleague's essay, and acknowledge that science is indebted to him for having been the first to call attention to interesting facts, and although I admit also that cross-paralysis is often caused by a lesion of the pons Varolii, as the cases which he has published show, I think that it is carry- ing generalization too far, when this form of hemiplegia is regarded as an absolute sign of a lesion of the pons. The explanation of this singular form of paralysis escapes us in some cases, and, after all, the same thing happens in a good many cerebral diseases which are still so very obscure. LECTURE L. FACIAL PARALYSIS, OR BELL'S PARALYSIS. Facial Hemiplegia: its Causes and Symptoms.- Contraction of the Muscles consecutive to Paralysis of one side of the Face may be mistaken for Paralysis of the opposite side.-Treatment.-Double Facial Paralysis. Gentlemen : Facial paralysis is an affection which is often met with in practice, and although it is in general of no gravity, yet treatment, unfortunately, fails too often to cure it. However mild the disease may be in the majority of cases, it sometimes excites singular alarm in the patients and those around them ; and it is all the more important that the physician should know well how to recognize it, that it still pretty frequently gives rise to lamentable errors of diagnosis. In order to put you on your guard against such mistakes, I wish, in this conference, to call your attention to some special points relating to this subject, apropos of two individuals suf- fering from this paralysis, whom you have seen-one in St. Agnes Ward, and the other in the neighboring ward of St. Louis. The young man in St. Louis Ward is 17 years old. He tells us that, through his being prevented from working by a slight wound in his hand, he spent his time in the streets and in public promenades; that on Monday last he slept in the open air on a heap of pebbles; that he was in a state of perspiration at the time, and got cold after falling asleep. He went home in the evening, feeling uncomfortable. The next morning, however, he got up, as usual, feeling absolutely no disturbance of his health ; but when he began to eat, he felt something peculiar, and had some difficulty in masticating. When his food got between his right cheek and his teeth, he was compelled to squeeze the cheek with his hand, so as to push the food between his teeth again. He was surprised at this, and could not account for it, as it was unaccompanied by any painful sensation. He felt more surprised when one of his friends, on seeing him, told him that his mouth was awry, and that it became considerably more so whenever he laughed. On then looking at himself in a glass, he verified the fact, and feeling frightened, came to the hospital to be cured. 896 FACIAL PARALYSIS, OR BELL'S PARALYSIS. The following points I ascertained myself: When the patient's face is at rest, the right side merely looks slightly flatter, and more flaccid than the left; his right eye is also more widely open than the left, but his physiog- nomy, after all, does not look strange. When he speaks, and still more when he laughs, the left angle of his mouth is immediately drawn upwards and outwards, while the right one is perfectly motionless. As the eyelids, the cheek, and the lips are motionless also, the face has in consequence a singular expression, especially when the patient tries to contract his muscles. The eyelids being motionless on the right side, the right eye cannot be completely closed; but the globe of the eye itself moves perfectly, at the patient's will, to the right or to the left, upwards or downwards. Sight is in nowise altered. The motor muscles of the eye are not therefore in the least at fault, and the paralysis (for there is paralysis present) affects ex- clusively the orbicularis palpebrarum, without involving the levator palpe- brae superioris. When the patient is asked to put out his tongue, he does so with perfect regularity; and the difficulty which he has in articulating certain words is not owing to defective action of the muscles of that organ, but to the immobility of the right cheek. On examining the fauces, it is evident that the double arch formed by the pillars of the soft palate and the mouth has not on both sides the regular form which it normally has, for the left arch is narrower than the right, showing that the uvula inclines to the left. I have told you how the complaint originated. Save a few hours of malaise, the patient has never felt any general disturbance, or the slightest headache; nay, more, he states that he has never felt better, and that his appetite is twice as good as formerly. I do not, of course, attach great im- portance to what he says, because he is doubtless prompted by the fear of being put on too strict a diet. This circumstance is sufficient, however, to show that there has never been any disturbance of his health, and that his complaint consists merely in a motor affection of the muscles of the face, the cutaneous sensibility of which is in nowise perverted. As to other loco- motor apparatus (the limbs, for example), their functions are discharged perfectly. The case, then, is one of that form of paralysis which has been named Bells paralysis. In the case of the other man, who occupies one of the first beds in St. Agnes Ward, the paralysis of the face occurred under different circum- stances. His health has been generally good, and he was smoking his pipe at a window during the heavy storm which burst over Paris a few days ago. A sudden and violent thunderclap in the neighborhood fright- ened him very much, but laughing at his terror, he soon resumed his place at the window, and went on smoking; but he perceived that he had some difficulty in spitting out, and a few moments afterwards his wife noticed that his face was distorted. As a few days elapsed without this distortion disappearing, he felt anxious about it, and came to the Hotel-Dieu. In this case, then, mental emotion, intense fright, brought on the same com- plaint as cold did in the case of the young man in St. Louis Ward. In both these men paralysis of one side of the face set in, impairing movement alone, and involving exclusively the muscles supplied by one of the seventh pair of nerves. These two cases are instances of that kind of facial hemi- plegia which has been termed idiopathic, in the language of schools ; mean- ing thereby that the complaint occurs independently of all appreciable ma- terial, traumatic lesion, whether inflammatory or not, affecting the facial nerve primarily or secondarily. FACIAL PARALYSIS, OR BELL'S PARALYSIS. 897 I shall now rapidly review the different causes under the influence of which facial paralysis may occur. Cold is one of the most frequent of these, and it would not be difficult to collect a great number of cases analogous to our first one, for this kind of paralysis has for a long time been spoken of by authors under the name of rheumatic paralysis. The patient is seized in the midst of the most perfect health, without there being any disturbance of the general economy: a mere draught, residence in a damp place, or in a newly-built house, may bring it on. You have seen that mental emotion may cause it, as in the case of the patient in St. Agnes Ward, who was greatly frightened. In others, the paralysis came on after a violent fit of anger, and in others again, after some profound grief, caused, for instance, by the unexpected death of a dear friend. Sometimes, also, the disease cannot be ascribed to any ap- preciable cause. In all the cases in which it is not owing to the presence of an appreci- able material lesion, the disease sets in suddenly; and the same thing happens when the paralysis results from fra-unuiiie lesions of the nerve. You know, gentlemen, that it is not of uncommon occurrence to meet with facial paralysis in newly-born children, and that it is sometimes mis- taken by careless persons for a symptom of cerebral disease. This paralysis, which is due to the compression by the forceps of the facial nerve as it emerges from the aqueductus fallopii, is generally transitory and of no gravity whatever; when the compression, however, has been excessive, it may persist through life. Your professors of surgery have pointed out to you this traumatic cause of facial hemiplegia, and they have also taught you that this paralysis could be the consequence of wounds of the seventh pair, inflicted either by accident or during a surgical operation. This form of paralysis may result also from a fracture of the skull, involv- ing that part of the temporal bone in which lies the aqueductus fallopii. In all these cases the paralysis, I repeat, occurs suddenly.. But there are instances in which it comes on slowly and by degrees-namely, when it is the consequence of a lesion which affects the facial nerve secondarily, as when some organic alteration in its neighborhood after a time compresses the nerve in some part of its course, or alters its structure. You know the course and distribution of the seventh nerve. You know how, emerging from the lateral column of the cord just as this column passes under the pons, it enters the internal auditory meatus, goes through the flexuous canal of the aqueductus fallopii, and comes out of the skull through the stylo-mastoid foramen; and how it then gives off several small branches-the posterior auricular, stylo-hyoidean, and infra-mastoidean- and then divides into two branches, the cervico-facial and temporo-facial. Now, before it enters the temporal bone, and after it has issued from it, this nerve is sometimes involved in tumors, which, whether they be devel- oped inside the cranial cavity or in the region of the parotid, may compress or disorganize it. It is far from being safe from all accident while it trav- erses the temporal bone; necrosis or caries, and suppuration of that portion of the temporal bone, may bring on destruction of the nerve and,, as a con- sequence, paralysis of the parts which it supplies. Several, instances of this have come under my notice-one, among others, in a boy seventeen months old, who died in one of my wards at the Necker Hospital, and whose case was published in the "Bulletin General de Therapeutique" for January, 1847. From what I have just told you, gentlemen, you may foresee that your vol. i.-57 898 FACIAL PARALYSIS, OR BELL'S PARALYSIS. prognosis should not be favorable in every case of Bell's paralysis. I will add that, in some very rare instances, this affection is due to a cerebral lesion. Graves states that he has twice seen paralysis exclusively limited to the face in small cerebral hemorrhages ; and my colleague in the hospitals, Dr. Duplay, has recorded several cases of the same kind in a very remark- able memoir. Graves makes the remark that paralysis which is thus local- ized is not very extraordinary, since cerebral hemorrhage pretty frequently manifests itself only by paralyzing the tongue or one arm. I have very frequently met with individuals in whom there had evidently been a very limited extravasation of blood, and whose features were considerably dis- torted, although they did not complain of weakness in the limbs of the same side. It must be added, however, that when such patients are ex- amined with great care, when they are asked to get up and walk, there may be perceived a certain hesitation in the movements of their leg of which they are not conscious ; and if their strength be tested by means of Burq's dynamometer, it is found that the pressure made on the instrument by the hand on the same side as the paralysis of the face, is evidently less than that made by the other hand. I am therefore very much disposed to believe that the illustrious Dublin physician has not had recourse to the various tests which I have just mentioned in the case of the two individuals whose history he relates very concisely. As to the instances recorded by Dr. Duplay, they have not convinced me; and it seems to me that in the first two cases, which he gives as typical ones, there had been at separate periods Bell's paralysis and cerebral hemorrhage, diseases which by no means exclude one another. But does it never happen that a cerebral lesion produces facial paralysis presenting the characters of Bell's paralysis ? There are cases of the kind, as, for instance, in lesions of the pons Varolii, as M. Vulpian's experiments have conclusively shown. He found that a very slight wound of the fourth ventricle produced paralysis of the face having all the characters of Bell's paralysis, even those indicated by M. Duchenne (de Boulogne)-namely, the absence of all electric excitability of the muscles supplied by the seventh pair. It is conceivable, therefore, that if a small hemorrhage occurred in a very limited spot of the pons, it could give rise to the symp- toms of Bell's paralysis exclusively. But such cases are so very rare that, in the course of a very long practice, I have not yet met with a single instance of the kind. On the contrary, it pretty frequently happens, as I was telling you just now, that ir cerebral hemorrhage without lesion of the pons Varolii, there is predominating paralysis of the muscles of the face, simulating Bell's paralysis. Let us try then and distinguish them. Now, there is a capital point of distinction, of which I have already told you, and on which I cannot insist too much-namely, paralysis of the orbicularis palpebrarum. However complete hemiplegia of cerebral origin may be, I have never seen complete paralysis of the orbicularis palpebrarum; the eye can always be closed; whilst in Bell's palsy, paralysis of the orbicu- laris palpebrarum is never absent, and the eye cannot be completely closed. Dr. Cazalis, physician to the Salpetriere, has like me paid attention to this point of symptomatology, and he declares that he has never seen a single case of cerebral hemorrhage or softening, in which the patient was unable to close his eye on the affected side, however grave the paralysis might be. Yet, in some exceptional cases, all the branches of the facial nerve are not affected (those, for example, which supply the muscles of the eyelids may escape), so that the symptom which I just now pointed out to you is some- times absent. In such cases one should have recourse to the sign mentioned by Duchenne, to which I alluded just now, and which has been confirmed FACIAL PARALYSIS, OR BELL'S PARALYSIS. 899 by Vulpian's experiments. In facial paralysis of cerebral origin, the mus- cles respond normally to electric irritation, whilst their contractility is not at all or scarcely at all roused by an electric current, if the paralysis be owing to an injury to the seventh pair. In cases of severe chronic otitis, with destruction of the tympanum and ossicula, it is not uncommon to find the petrous portion of the temporal bone in a great part carious, and to see facial paralysis come on. Whilst I was physician to the scrofula wards in the Hospital for Sick Children, I have often pointed out to the pupils who went round with me the relations between chronic diseases of the internal ear and Bell's paralysis. But the disease does not, unfortunately, confine itself to destroying the facial nerve in its passage through the aqueductus fallopii; it attacks the cranial surface of the petrous portion, and on the pus raising and then perforating the dura mater, abscesses are formed in the base of the skull, and purulent infiltrations of the arachnoid result, to which Abercrombie and Hamilton were the first to call the attention of practitioners. Those are terrible acci- dents, which perhaps never spare life, as you saw last year so sad an in- stance in the patient at No. 30 in St. Bernard Ward. In some cases the pus makes its way even into the spinal cavity; and I cannot help quoting to you, in reference to this point, the history of a boy, ten years old, who was attended by Dr. Graves (of Dublin) : "A boy, about ten years old, was admitted into the Meath Hospital, laboring under general dropsy. He appeared of a scrofulous habit, and was much worn down by long-continued diarrhoea. Under appropriate treatment his symptoms gradually but slowly disappeared, and he was restored to comparative health. We now observed that the right side of the face was affected with paralysis, and on examination found that he had been subject to a discharge from the right ear for seven years previously. The paralyzed cheek presented the phenomena usually observed in ' Bell's paralysis.' He was attacked soon after with acute pain in the ear, and in the left side of the head ; a fortnight after, convulsions set in; the pain moved from the side to the back of the head, then to the back of the neck, and ultimately extended the whole way down the spine, and about this period the otorrhcea diminished. A few days before death he was attacked with spasms resembling those of tetanus, and the stirface of the body became exquisitely tender to the touch. He never had any loss of motion, and to the last his intellect was perfect. " From the period when the pain set in to that of his death, the convul- sions returned about six times. " Post-mortem.-The portio dura was dissected on the face, and found healthy ; the nerve was also healthy, from its origin at the base of the brain to its entrance at the meatus auditorius; immediately above this opening the dura mater was of a greenish color, detached from the bone, as if by fluid, and perforated by a round hole, large enough to admit a small crow- quill. On dividing this part of the membrane, the space between it and the bone was occupied by a thick, greenish, and offensive pus, and the open- ing in the dura mater was observed to lie exactly opposite the foramen in the petrous portion of the temporal bone, called the aqueductus vestibuli; this opening was much enlarged, and the bone around it was in a carious condition. The nerves at the base of the brain were bathed in this thick green pus, but the organ itself was everywhere healthy, and free from any excess of vascularity. The spinal arachnoid was also filled with the same kind of matter, but the spinal cord itself presented no trace of disease."* * Graves's " Clinical Lectures," vol. i, p. 569. 900 FACIAL PARALYSIS, OR BELL'S PARALYSIS. The symptoms of facial paralysis vary according as the lesion to which it is due is seated at a more or less distant point from the origin of the seventh pair. But, whatever be the seat of the lesion, the patient's physiognomy wears a strange aspect, which is perfectly characteristic. Even in the state of repose, there is a striking want of symmetry between the two halves of the face, owing to the absence of antagonism in the muscles, which give regularity to the features through their co-ordinate contraction. The sound cheek looks wrinkled and shortened; the labial commissure on that side is drawn outwards and upwards, and is on a higher level than the opposite one. When the paralysis is very marked, the commissure on the affected side remains half-open, and the saliva escapes constantly through it. Moreover, the cheek is flaccid from paralysis of the buccinator muscle, and yielding in forced expiration to the pressure of the air exerted from within outwards, it swells out and then falls down flapping, like a curtain as it were, in front of the rows of teeth and of the interval between them. Breathing is badly performed through the nostril on the affected side, from its no longer opening as it does normally, and remaining more closed than it should be and than it indeed is on the sound side, towards which the tip of the nose is slightly drawn. The eye is, on the contrary, more widely open, although the eyebrow is lowered, from the corrugator supercilii being paralyzed and unable to keep it up: the eye looks also larger and more prominent than its fellow. The lower lid is everted and depressed, whilst the upper lid, being now under the influence of its elevator muscle alone, is drawn up and maintained in that position. In a pretty good number of cases, there is a constant flow of tears, and the epiphora-which is all the more copious that the irritation of the conjunctiva causes the lachrymal gland to secrete more abundantly-is due partly to the fact that the lower lid no longer forms a canal for the tears, and partly (but chiefly) to pa- ralysis of that portion of the orbicularis which forms Horner's muscle. The lachrymal puncta, which it is the office of this muscle to pull inwards and to make prominent, can no longer assume that position, and therefore no longer receive the tears which do not find their way into their normal channels. Dangerous consequences to the organ of sight may result, in facial paral- ysis, from the absence of winking, as sometimes happens in grave fevers from the same cause. For you are aware that three sets of nerves partici- pate in the act of winking: (a) branches of the fifth pair, which are sen- sory, and give rise to the sensation of the want of winking; (6) branches of the seventh, which are motor and preside over the contraction of the orbic- ularis muscle, and consequently over the closure of the eyelids; and (c) lastly, branches of the third pair, the motor occuli communis, which pre- sides over the contraction of the levator palpebrse superioris, the muscle which opens the eyes. The use of winking is to protect the globe of the eye against any external injury, and especially to spread over its surface the tears, which lubricate the membranes that enter into its composition and preserve their limpidity. Now, as soon as a lesion of the facial nerve brings on paralysis of the orbicularis, the patient can no longer wink, and hence his tears are no longer spread over the surface of the globe of the eye, or are only imperfectly spread : besides, from its remaining constantly open, the eye is exposed to the irritating action of the air, and becomes the seat of inflammation, which increases more or less rapidly. The conjunc- tiva is red and injected, the cornea becomes dry and opaque, ulcerates, and is then perforated, and the eye is lost, in the same manner as in grave con- tinued fevers. These dreadful consequences are not common, however, in cases of facial paralysis, because, on the one hand,, winking is in part sup- FACIAL PARALYSIS, OR BELL'S PARALYSIS. 901 plied by the movements of the eye, which are performed by its intrinsic muscles ; and, on the other hand, the patients instinctively remedy the absence of winking by lowering from time to time with their fingers the palsied lid, so as to rub with it the surface of the eye. When the patient's face gets animated-when he speaks, laughs, or tries to contract the muscles of his face, the deformity characteristic of facial paralysis becomes considerably more apparent, from the immobility of the palsied side contrasting singularly with the exaggerated mobility of the sound side. The labial commissure on the sound side is pulled up- wards and outwards; the nostril rises and opens, the eye can be closed at will, and the forehead thrown into wrinkles; whilst on the diseased side, the labial commissure remains lowered, the nostril closed, the forehead smooth. When the patient speaks, he has some difficulty in pronouncing labial consonants and vowels. The tongue, however, remains in general free, and is protruded in its normal direction, although it apparently deviates, owing to the normal relations between the two labial commissures and the median line being lost, in consequence of which the apex of the organ seems to point away from the median line on the side corresponding to the paralysis. There are yet cases in which the tongue is paralyzed, and really deviates, namely, when the branches which the facial nerve sends to the stylo- glossus and genioglossus muscles are involved. In such cases there exists, also, a peculiarity which several observers have pointed out, and which I noticed myself in the case of the young man in St. Louis Ward; I mean paralysis of a portion of the velum palati and uvula, and deviation of the latter. You could see, when you looked into the throat of this patient, that the uvula inclined to the left side (the facial paralysis was on the right side), so that the semi-arch comprised between it and the pillars of the soft palate was markedly much narrower than the semi-arch on the right side. Paralysis of the tongue and soft palate is an uncommon complication of facial paralysis after all, and can only be explained by admitting that the lesion of the seventh nerve is seated near the origin of the nerve, or at the very least before it bends at the genu, in the aqueductus fallopii; for it is at that part that the nerve gives off the branches which go to the spheno- palatine ganglion, from which proceed the branches destined to the muscles of the soft palate, to the styloglossus, and the genioglossus. In consequence of the paralysis of the orbicularis oris, the patient can- not perform certain actions, such as that of spitting, or at least he has great difficulty in spitting to a certain distance; and you may remember that this was the first symptom which made the patient in St. Agnes Ward no- tice the accident which had happened to him. He could no longer whistle, and when he attempted to inflate his cheeks, by blowing while his mouth was shut, he could not keep the air in, and it escaped through his half- opened lips. Mastication is itself impeded. The paralyzed buccinator being unable to push back the food into the cavity of the mouth, as it does normally, the food accumulates outside the row of teeth, in the sort of pouch formed by the distended cheek, and the tongue must constantly go there after it. It frequently happens that the patient is even obliged to use his fingers in order to get the food back between his teeth, or he supports with his hand his paralyzed cheek while eating, in order to prevent it from getting dis- tended-thus instinctively supplying the place of the muscle which no longer acts. While motility is thus impaired, tactile sensibility is perfect in the para- 902 FACIAL PARALYSIS, OR BELL'S PARALYSIS. lyzed parts, although it occasionally happens that the sense of taste is per- verted on the side of the tongue which corresponds to the motor paralysis. On October 8, 1863, I was consulted by a patient attended by M. Perate. Two months previously he had got wet through, while riding outside an omnibus. A few days afterwards he went on a railway journey, and the window being down, the left side of his face was exposed to the wind. On the following day it seemed to him, when he ate, that his food tasted (to use his own words) like " salt plaster." After another day, the left side of his face was completely paralyzed. The alteration of the sense of taste was still present when I saw the patient, although to a less degree. Is this perversion of taste a proof that the chorda tympani is a sensory nerve ? or is taste modified only because this nerve influences the secretion of saliva, as it has been shown to do by Claude Bernard, and any injury to it causes modifications of that secretion, the utility of which is indispen- sable for the regular action of the sense of taste. Tactile- sensibility is not only preserved, but there is also, in some cases, a sensation of pain in the affected parts, due to the rheumatic agency under the influence of which the paralysis set in. It seems, gentlemen, that there can be no possibility of error in a case of facial paralysis, or that the whole question of diagnosis consists merely in investigating the causes which brought on the complaint. Yet the case of a young woman, lying in bed No. 7, St. Bernard Ward, has shown you that this diagnosis was not always so simple as one would imagine. You remember how the patient to whom I allude was admitted into the Hotel- Dieu for a puerperal affection, into the history of which I need not go here, and which was besides of no gravity. From the first day I saw her, how- ever, I was struck with the deformity of her face, which, at first sight, sug- gested the idea of paralysis of the left side of the face; for her face was distorted, and deviated notably to the right. The upper lip and the ala nasi of that side were drawn upwards; the labial commissure was pulled upwards and outwards; the naso-labial sulcus, which was also pulled up- wards, was deeper than normal, whilst the corresponding nostril was less open than the other. Yet the eye on that side looked larger than the left eye; the under lid was depressed, and slightly everted; and the tears, which were abundantly secreted (especially when the patient had looked at some object), flowed over the cheek instead of through their normal chan- nel : at such times, also, the sight was somewhat obscured. On carefully examining the patient's face, one was not long before notic- ing that there occurred, on the right side, slight convulsive movements, analogous to those which characterize spasmodic tic. Those movements were spontaneous, but could also be induced by rubbing the cheek or the upper lip with the tip of the finger or a penholder, or by gently tickling the skin of those parts. If left facial paralysis was thought of at first sight, the depression of the lower lid, and the less marked expansion of the nostril on the right side, were already sufficient to cause a modification of the diagnosis. But when the patient attempted to move that side of her face, there could no longer be any hesitation, and it became manifest that it was the right side which was affected. When she spoke, and still more when she laughed, her face was pulled with force to the left, the upper lip and the ala nasi on that side going obliquely upwards, and the labial commissure being drawn with con- siderable energy upwards and outwards. When she attempted to blow, her left cheek swelled out, and her mouth remained closed on that side; whilst her right cheek was flaccid, and her mouth opened out a little on FACIAL PARALYSIS, OR BELL'S PARALYSIS. 903 that side. Besides, she could not shut her right eye, however much she tried. She gave us the following account of her case: She had had complete paralysis of the right side of the face eight years previously. It had set in suddenly, subsequently to a cold caught during a walk by the seaside, after she had had a tooth extracted. For eight months the application of leeches and other therapeutic measures were vainly tried against this affection, which was accompanied by violent pain in the head, and which yielded at last under the influence of a treament by localized electricity carried on for four months. She seemed to be radically cured. Her fea- tures had completely recovered their regularity, when the new change, which attracted my attention, occurred, and which the patient stated she had perceived of late only. Several medical men, whom she had consulted since then, mistook, not the nature of the disease, but the seat of the paralysis, placing it on the left, whilst it was undoubtedly on the right; for no one among you can doubt that we have, in this case, to deal with convulsion and contraction of the muscles of the face, consecutive to paralysis. We could here suppose, gentlemen, but could not affirm, the existence of a relation between the facial paralysis and the convulsion of the muscles supplied by the seventh pair, although this convulsion might well be a coincidence only. Indeed, what Graves has called spasm of the portio dura of Bell, or, in other words, spasm of the facial muscles, occurring indepen- dently of all painful affection and of all paralysis, is pretty common; and Graves relates a very curious instance of it in his thirty-eighth lecture. I have often seen it myself-generally, it is true, in connection with neuralgia of the fifth pair, with that variety of neuralgia which I have termed epi- leptiform, and of which I have spoken to you at length. Simple contraction of the muscles of the face is very common after Bell's paralysis. In the case of the young woman to whom I alluded just now, it was partial, as it most commonly is; the raised upper lip and ala nasi, and the deviation of the corresponding labial commissure, indicated that the contraction only involved the orbicularis oris, the zygomatici, the buc- cinator, and the levator alee nasi et labii superioris; whilst the depressed lower lid, the less expanded nostril on the right side, showed also that the orbicularis palpebrarum and the dilator muscle of the nostril (transversus pinnse) were still paralyzed. The contraction was, besides, mixed up with some degree of paralysis, as was shown by the want of power of contracting at will the affected muscles. I have often already, and for a long time past, called your attention to the contraction of the facial muscles which follows Bell's paralysis. There then occurs a process analogous to what we observe in other muscles in cases of hemiplegia due to cerebral hemorrhage or softening. As I have had occasion to tell you, when the hemiplegia has been such as to abolish all movement for several weeks, it rarely happens that the muscles of the arm and forearm do not become contracted irremediably. If you visit hospitals for the aged, you will be struck with the extreme frequency of this affection. The forearm, in such cases, is half-flexed on the arm, the hand on the fore- arm, and the fingers (more particularly the two last phalanges, and the ungual phalanx of the thumb) are forcibly bent into the palm of the hand. The contraction is sometimes a little painful, and attempts can never be made to overcome it without causing acute pain, and the same result follows when the muscular masses suffering from this spasm are firmly compressed. Contraction, following paralysis, is therefore of extremely common occur- rence, and it is perfectly natural that it should come on after Bell's paral- 904 FACIAL PARALYSIS, OR BELL'S PARALYSIS. ysis, when this affection has been carried to an extreme degree, and has lasted a long time. There was last year in my wards, if you recollect, another very striking instance of this. Of course all the cases are not exactly alike-that is to say, one muscle will be at one time contracted, and another muscle at another time. In one patient, the orbicularis palpebrarum will be affected, and the consequence will be that the eye, instead of being more open than the other, will close and look smaller; in another, as in our young woman, the buccinator and the zygomatic will be contracted. It may also happen that the muscles become shorter in course of time, in which case there will not only be a simple deformity of the face, but also a considerable impedi- ment in its mobility. This contraction of the muscles of the face is, I repeat, a frequent termination of the so-called rheumatic paralysis of the seventh pair. Dr. Duchenne, in his treatise on " Localized Electrization," has devoted an interesting chapter to this subject. I am the more surprised at our classical works making so little mention of it, that muscular contrac- tion, sequential to paralysis of the limbs or trunk, is a symptom which has been universally indicated. It was necessary to fill up this omission in the history of facial paralysis, in order to put you on your guard against possible errors of diagnosis. A little care will be sufficient to make you avoid them. As to the differential diagnosis of the various kinds of paralysis from one another, it should be based on a knowledge of the circumstances in which the complaint set in, of the course of its development, and the concomitant phenomena. In one of our previous conferences, I have dwelt long enough on the dif- ferential characters of Bell's paralysis, and of facial paralysis symptomatic of a central affection, such as hemorrhage, and I need not return to the subject now. There are embarrassing cases, however-namely, when the facial paralysis is due to a tumor of the brain, developed either in the men- inges, or in the substance of the organ itself, or in the petrous portion of the temporal bone, in the neighborhood of the spot where the seventh nerve enters the aqueductus fallopii. The cause of the paralysis, especially when it sets in suddenly, may be mistaken, and it may be thought of a rheumatic nature. Such cases are, fortunately, very rare; and other phenomena enable one besides to make, before long, a correct diagnosis. Idiopathic facial paralysis generally gets well, and all the more rapidly that it set in suddenly, and the patient is young. There is an important point which you must know, however-namely, that under certain circum- stances the complaint stubbornly resists all treatment, although nothing in the phenomena which characterize it gives you a clue to this; whilst in other cases, presenting identical symptoms, the disease yields with the most marvellous facility. Dr. Duchenne (de Boulogne) has shown that localized electrization affords us a means of distinguishing such cases, abolition of the electric contractility of the palsied muscles being regarded by him as a certain sign of the incurability of the disease. Now7, gentlemen, a few words as to treatment. Above all, do not forget that facial paralysis is sometimes such a transitory complaint that it gets well in 24,15, and even 12 hours, before medicine has had time to interfere. Such cases ard exceptional, however. Antiphlogistics, leeches, and cupping in front of the ear, and on a level with the mastoid process, are indicated when the presence of pain, and a certain amount of swelling of the region about the parotid, seems to point to an irritation of those parts. When the disease is of a less acute character, remedies which stimulate the skin should be had recourse to, and, of these, blisters rank first. If they FACIAL PARALYSIS, OR BELL'S PARALYSIS. 905 fail, more energetic measures are called for, such as transcurrent cauteriza- tion, cauteries, and moxas. I have obtained pretty good results from the use of preparations of strychnine or of veratria, by the endermic method. I have the raw surface of a blister dressed with from 2 to 10 milligrammes to 1th of a grain) of sulphate of strychnine or of veratria, which are always mixed with five or six times their weight of powdered sugar. I have also seen some good done by the application, on the region of the parotid, of compresses steeped in tincture of nux vomica. Lastly, acupuncture, electropuncture, or elec- trization simply, have been found useful; but it should be remembered that faradization should be used according to certain rules, well laid down by Dr. Duchenne. It is not necessary for me to add, that all I have said on treatment refers merely to the so-called rheumatic paralysis, for it is self- evident that the paralysis caused by an accidental division of the nerve, or its destruction in diseases of the petrous portion of the temporal bone, is quite beyond the resources of art. As yet, I have only spoken of facial hemiplegia; but before concluding, I will say a few words about double facial paralysis, an affection which is not even mentioned in the treatises on medicine and surgery which are in your hands. Dr. Davaine, who has the merit of having brought together, in a long and important memoir, cases of this kind scattered through scien- tific records,* has summed up its characters. They vary according as the paralysis is general or partial, complete or incomplete. In the general and complete variety (the only one of which I shall speak here, for it is the only one which has been observed in man, partial paral- ysis of both facial nerves having been met with in the lower animals alone), the features have not lost their regularity, or, more properly speaking, there is no longer that want of symmetry which in the hemiplegic form arises from the absence of antagonism between the muscles of the affected side and those of the other. The motionless face assumes a peculiar aspect, and looks like a lifeless mask on which the impressions of the soul are no longer expressed but by changes of color. The forehead is smooth, the superciliary region lowered; the eyes are wide open and cannot be closed ; the lower lid is half-depressed, and, as in the hemiplegic form, the tears flow constantly over the cheeks, while the half-opened lips allow the saliva to run out of the mouth. The nostrils, already diminished in calibre, fall in still more during inspiration, while in forced expiration the cheeks are puffed out, soon to sink in again like loose sails. The other symptoms which I mentioned to you when speaking of facial hemiplegia-namely, the difficulty of mastication, the inability to spit out, to whistle, or to blow, the difficulty in pronouncing certain consonants and the labial vowels- are much more marked in double facial paralysis; the voice, besides, has a nasal twang, because the soft palate, which is sometimes involved, as we have seen, in facial hemiplegia, is generally much more completely so in the double form of the disease. On looking down into the patient's throat, there is no deviation of the uvula as in hemiplegia, nor diminution in the diameter of one of the arches comprised between the uvula and the corre- sponding pillars; the two arches are symmetrical. But this complete paralysis of the soft palate causes, in addition to the nasal twang of the voice, difficulty of deglutition, and the return through the nose of the liquids drunk. The difficulty of deglutition is due to other causes also-in * Memoire sur la paralysie generale ou partielle des deux nerfs de la septieme paire. (Mem. de la Soci€t£ deBiologie, 1852, et Gazette Medicale de Paris, 1852 et 1853.) 906 FACIAL PARALYSIS, OR BELL'S PARALYSIS. part to the paralysis of the posterior belly of the digastric and of the stylohyoid muscles, which are supplied by a branch of the facial nerve, and the latter of which raises the base of the tongue; and in part to the paralysis of the pharynx itself, which is also supplied by branches of the seventh pair : lastly, the tongue can no longer be protruded out of the mouth with ease, nor its tip curved upwards. You understand, gentlemen, that it is impossible to speak in general terms of the course, the duration, and the termination of double facial paralysis, because these are, in fact, necessarily subordinate to the causes which produce it. These causes are sometimes lesions of the nervous centres, such as extrav- asations, softening, &c., the symptoms of which are limited to the muscles supplied by the nerves of the seventh pair, as in one of the cases recorded by Dr. Davaine, although we find it impossible to explain by the anatomi- cal lesions why the paralysis was so localized. Sometimes the cause is some affection involving the two facial nerves in their course through the petrous portion of the temporal bone. Thus, Dr. Davaine relates an instance of double facial paralysis resulting from a vio- lent concussion, which had fractured both temporal bones at the same time. Now, in such a case, the paralysis is explained by compression or laceration of the nerves. But one may conceive how a morbid influence capable of acting on several organs at the same time, and especially on the bones, such as scrofula and syphilis, will be more liable than any other to produce a simultaneous lesion of the two temporal bones, and thus to bring on double facial paralysis. The author whom I mentioned just now, bor- rows from Sir C. Bell a case observed by Dupuytren-namely, that of a girl, sixteen years of age, who had double facial paralysis, beginning on the left side, and involving the right a week afterwards, and which disap- peared under the influence of an anti-syphilitic treatment carried on for eight months. I read, a few days ago, in the " France Medicale," a similar case extracted from the " Dublin Quarterly Journal," and published by Dr. O'Connor. The patient had for a long time exhibited symptoms of constitutional syphilis, and was particularly suffering from periostitis of the cranial bones. The facial paralysis in this case also showed itself first On the left and then on the right side. Hearing was not impaired, and there was no disturbance of the intellect, although, judging only from his aspect, the patient looked a perfect idiot. The features were expressionless. The eyes were constantly staring, injected, red, and bathed in tears, which kept dropping on the cheeks. The flaccid and hanging commissures of the lips allowed the saliva to escape, as well as any liquids which the patient attempted to swallow, deglutition being performed with considerable diffi- culty only. As the lips could no longer be used for articulation, the voice was guttural, and seemed to issue from the bottom of the throat. As the patient's life was not in danger, the expression of his face excited laughter more than a feeling of pity, so that the jokes of his companions made him leave the hospital, and Dr. O'Connor was not able to find out how the disease terminated. A third class of causes of this double facial paralysis includes those which act on the nerve as it issues from the stylo-mastoid foramen and on its peripheral ramifications-such, for instance, as cold, and compression by the forceps at the time of delivery. Before leaving this subject I must call your attention to the fact that double facial paralysis has been confounded with another variety of incom- plete paralysis of the face, which I have called glosso-laryngeal paralysis, FACIAL PARALYSIS, OR BELL'S PARALYSIS. 907 and which has been described by Dr. Duchenne (de Boulogne) under the name of progressive muscular paralysis of the tongue, soft palate, and lips. You no doubt remember how carefully I took notes of the cases of five individuals suffering from this affection, and who remained for several months in St. Bernard and St. Agnes Wards. These patients had paralysis of the soft palate, of the tongue and the lips; the articulation of certain words and of certain letters, the deglutition of saliva and of food, had at first been difficult and then impossible; but the paralysis had never spread to the upper half of the face. The muscles which are concerned in the act of laughing and in the closure of the eyelids had preserved all their con- tractility ; and even a few moments before their death, from asphyxia brought on by the paralysis of their respiratory muscles, or by the arrest of a bolus of food in the last portion of their pharynx, these patients could still show by the expression of their face their gratitude to those who at- tended them. In double facial paralysis, on the contrary, the mask is dumb, and hence the persistence of contractility in the upper half of the face, in cases of glosso-laryngeal paralysis, would alone be sufficient to save one from an error in diagnosis. I may add that in Bell's paralysis the tongue is never paralyzed to such a degree as to be incapable of being protruded out of the mouth. And if the patient speak with difficulty, it is less their tongue than their lips which fail in the articulation of words. Dr. Davaine, however (at a time, it is true, when glosso-laryngeal pa- ralysis had not been yet described), mistook that affection for double facial paralysis, and his memoir contains two cases of it (Cases VII and VIII). I confess that a mistake may easily be made, because in that singular par- tial paralysis the orbicularis oris and the tongue can scarcely move; and as in the act of speaking the movements of the mouth are of necessity most frequently repeated, and as most of the facial muscles converge to- wards the mouth, the patient suffering from this complaint seems to wear a motionless mask, as if he had double facial paralysis. On looking closely at him, however, it is ascertained that the orbicularis palpebrarum and the other muscles of expression have retained all their energy, while this is not the case in Bell's paralysis. Moreover, the muscles invariably retain their electric excitability, whilst in Bell's paralysis this property is abolished or nearly so. Dr. Davaine gives, after Marshall Hall, a test by which it may be ascer- tained whether the cause of double facial paralysis is seated in the brain or in the course of the nerves. In the former case the conducting power of the nerve-trunks is retained for an indefinite period, so that by galvanizing the trunk and the principal branches of the facial nerves, all the muscles supplied by them are thrown into contraction, as if the muscles themselves were being galvanized ; whilst, when the paralyzing cause is in the course of the nerves, they very easily lose their conducting power. Moreover, if reflex movements be seen in the paralyzed muscles, it will be a sure proof that the cause of the paralysis is in the nerve-centres. When once the seat of the paralysis has been determined, and its cause known or suspected, they will indicate the proper treatment which should be followed, and I need not repeat what I have already told you when speaking of facial hemiplegia. 908 ON GLOSSO-LARYNGEAL PARALYSIS. LECTURE LI. ON GLOSSO- LARYNGEAL PARALYSIS. There is a form of paralysis which is always progressive in its course, fatal in its termination, and which is marked, at its onset, by a diminution of motor power in the tongue, the soft palate and the lips. I give to this affection the name of glasso-laryngeal paralysis, in order thereby to indicate the principal symptoms which characterize it. This is certainly not a new disease, and it must have been observed sev- eral times already; but as was the case with muscular atrophy, exophthal- mic goitre, and locomotor ataxy, it was confounded with other analogous affections. In 1841, after seeing a patient, in consultation with Dr. Vos- seur, I wrote a memoir which Dr. Vosseur preserved, and communicated long afterwards to Dr. Duchenne (de Boulogne), who kindly returned it to me. This memoir proves most peremptorily that I had well observed this variety of paralysis, but that case, to which I had not been able to add another, had remained a dead letter for me. The memoir was as follows: "We find that Prince M is unable to speak and to articulate any other letter besides the letter a; moreover the extreme difficulty which he has in swallowing immediately drew our attention to the organs of phona- tion and deglutition. " We ascertained, first, that the soft palate is motionless and does not contract even when directly excited; the tongue moves with difficulty, and the patient cannot curve its tip upwards, and can scarcely protrude it be- tween the teeth. " When a finger is passed down into the throat, no swelling or tumor is found at the upper part of the larynx. The introduction of the finger gives pain, but whilst the larynx is carried upwards spasmodically by its extrinsic muscles, the pharynx itself does not contract very manifestly. We thought that there was no laryngeal phthisis in the sense usually un- derstood by this word. " The preservation of the principal vocal sound a and its extreme dis-, tinctness, indicated that the vocal cords were unaffected. The inability to pronounce the four secondary vowels was solely and perfectly explained by the lesion of the vocal apparatus external to the larynx; just as the ina- bility to pronounce consonants was accounted for by the affection of the tongue and lips, parts which are chiefly concerned in the formation of these sounds." We summed up our opinion by saying: "The undersigned think that all these functional disorders are due to weakness of the muscles of the pharynx, the larynx, the soft palate, the tongue, the lips, and the cheeks. " Similar weakness exists in a very marked degree in the left arm; is a little more pronounced in the left than in the right side of the face; con- siderably so in the diaphragm, and only slightly marked in the abdominal muscles, the bladder, and rectum. " The consultants have thought that there existed in the nervous centres, ON GLOSSO-LARYNGEAL PARALYSIS. 909 and perhaps in the nerve-trunks, such a modification that the influx was no longer normally and sufficiently distributed. " They have asked themselves what this modification could be, and it has seemed to them easier to say what it was not, than to state precisely what it consisted in. They have thought that there was neither chronic softening of the nerve-substance, nor effusion of blood, nor a tumor, and they have felt inclined to admit a lesion of the same nature as those which so often give rise to amaurosis, to paraplegia, or to facial paralysis, lesions which dissection cannot always discover or determine." Surely, gentlemen, we had well seen that this case was a form of paral- ysis which had not been described in books, and this paralysis was the same which, twenty years later, Duchenne taught us how to recognize. We had noticed that the patient could only pronounce the letter a, and that the vowels o and u could not be articulated in consequence of the feeble contraction of the orbicularis oris. We had also noted the paralysis of the tongue, the soft palate, and the larynx, as well as the great difficulty of deglutition which existed, and we summed up our consultation by say- ing positively that the functional disorders were due to weakness of the muscles of the pharynx, the larynx, soft palate, tongue, lips, and cheeks. Far from me is all idea of claiming any priority as to the discovery of this new morbid species. I had seen it, but not seen it with its special characters, and I had soon forgotten it. Perhaps I might have remem- bered the case of Prince M , had other similar cases come under my observation. It is just, however, to observe that in Prince M I had noted symptoms of paralysis, with progressive tendencies, which have not been mentioned in Dr. Duchenne's memoirs, and which subsequent obser- vation has led me to regard as the fully developed expression of this dis- ease. Besides, we shall see by and by that all these symptoms have a com- mon bond of union, and originate from the same lesion which has certainly its seat in a portion of the nervous system. But before I give you a general description of this disease, I shall first relate the cases the symptoms of which will, when analyzed, serve as the basis of my description. Some of you may still remember that woman who was admitted into the St. Bernard Ward, No. 29, and whose progres- sive paralysis, dating from October, 1859, terminated in death in January, 1861. She was forty-seven or forty-eight years old, and a year before coming under my care she had been treated by Dr. Duchenne. She had first noticed that she pronounced some words badly; swallowing next became painful; saliva constantly dribbled out of her mouth; her voice had a nasal resonance ; her lips could no longer contract so as to allow her to give a kiss, to whistle, or pronounce the letters o and u; and, lastly, a few days before admission, aphonia had supervened. When I saw her for the first time in the beginning of November, 1860, I at once observed all the signs of the special progressive paralysis which Dr. Duchenne had just de- scribed in the " Archives Generales de Medecine." There were almost com- plete aphonia, considerable weakness of respiration, and extreme difficulty of deglutition: so much so, that one day the patient was nearly choked through the bolus of food stopping on a level with her larynx. The pro- gressive paralysis gradually became worse, respiration grew feebler from day to day, and the patient apparently died of slow and prolonged asphyxia. On making a post-mortem examination, no appreciable material lesion could be detected in the muscles the functions of which had been princi- pally disturbed, not even with the aid of the microscope. But it is to be regretted that the roots of the hypoglossal nerve, of the spinal accessory and of the spinal nerves, were not examined under the microscope, especi- 910 ON GLOSSO-L ARYNGE AL PARALYSIS. ally as we already knew the researches of Dr. Dumenil in a complicated case of paralysis of the tongue and progressive muscular atrophy. When the post-mortem examination was made, however, no modification was found in the size and color of the roots and branches of the hypoglossal nerve. Still I could not help thinking that there must have been some anatomical lesion of the nervous system, since there manifestly was none of the muscular tissue. In September, 1862, a compositor, aged seventy-two, was admitted into St. Agnes Ward, No. 23. He was of a robust constitution, and had always enjoyed good health until March, 1862. At that time only, he first noticed some defect in his pronunciation of certain words, his tongue felt embar- rassed, his voice was altered, and his speech was thick. Exactly as in double facial paralysis, the food lodged on each side between his cheeks and his teeth, and he was obliged to use his fingers in order to replace it on his tongue; occasionally also his voice had a nasal resonance. In June, 1862, these symptoms having become more distinctly marked, the patient requested to be admitted into the Hotel-Dieu. He was at first taken into Professor Rostan's ward, where I had occasion to see him for the first time. The difficulty he had in answering my questions, as well as the evident paralysis of his tongue and lips, reminded me not of the case of Prince M , for I had forgotten it, but of the woman who had been under my care in I860.* When this man tried to speak, he uttered a sort of grunt; he could not pronounce a single word distinctly, still less construct the simplest sen- tence, and although his intelligence was unimpaired, he answered only by signs. His face was expressionless, owing to the immobility of its lower portion and to his mouth being almost constantly open. On ascertaining what sounds he could utter, I found that he could still articulate the vowels a, e, i, but was unable to say o and u, for which the lips are indispensable., Nor could he articulate the consonantsp, b, m, n, k, c, t, which require more or less the intervention of the lips and tongue, as every one may satisfy himself by slowly pronouncing them. The other letters of the alphabet could be articulated, only however on the patient making efforts and pinching his nose so as to close the external nares, and send through the mouth the whole column of air expelled during expira- tion. The lips, when watched attentively, were seen to remain motionless during the attempts at articulation, at whistling, pursing up his mouth, or pronouncing o and u. ' The orbicularis oris did not contract any longer, so that the lips remained half open. Every moment the patient caught in a handkerchief the saliva which he was unable to swallow, and which his lips could not retain inside the cavity of the mouth. If he was made to laugh, his mouth afterwards remained wide open, his face looked like one of those masks used by the ancients in comedy, and he was obliged to bring his lips close together again with his fingers so as to close his mouth, and even then he succeeded imperfectly only. The tongue itself had in a great measure lost its mobility, and was lodged behind the lower row of teeth. It could not be protruded outwards, nor moved sideways, nor raised upwards to the hard palate; it could not be lengthened into a point, nor made hollow in the centre. Its extrinsic and intrinsic muscles, therefore, were paralyzed, and unable to aid in mas- tication, and assist in tasting the food by pressing it against the roof of the palate. This paralysis of the tongue must also have had a share in cans- * This case is reported in an Appendix to the " Trait6 d'Electrisation localisee," by Dr. Duchenne (de Boulogne). 2d edit. ON GLOSSO-LARYNGEAL PARALYSIS. 911 ing the difficulty in the first stage of deglutition. As to the paralysis of the soft palate, it was proved by the nasal resonance of the voice and by the food getting into the nasal fossae. The floor of the mouth itself was no longer tense; the larynx no longer rose with the same rapidity during the second stage of deglutition, so that it was probable that the mylo-hyoidei, stylo-glossi and stylo-hyoidei muscles, as well as the levatores and tensores palati, were also palsied. Perhaps were not the constrictors of the pharynx themselves paralyzed to the same degree, for occasionally the posterior aperture of the mouth and the nasal fossse, remaining wide open through the paralysis of the tongue and the soft palate, the food was rejected with violence, as if by a spasmodic contraction of the pharynx. Let us note also that the patient complained of a sense of constriction in the pharyn- geal region. A fact well worth noticing is, that in all the cases which have come under my own observation,, the paralysis did not remain confined to the muscles of the soft palate, tongue, and lips, but, after a variable period, extended to other parts of the body, and sometimes showed manifest tendencies to become general. Thus, the compositor whom I mentioned just now suffered from a marked diminution of contractile power in the right arm, which could not be attributed to an old wound. Thus, again, in the case of Prince M , of the woman in the St. Bernard Ward, and of the man whose his- tory I soon shall relate, the paralysis extended to the chest-walls, the bladder, and lower limbs. Yet, amidst all these disorders, the intellect was not affected, and the compositor, who could no longer make himself understood by speech or gesture, managed, by means of an alphabetical table, to compose words expressing his thoughts. . A good many measures had been tried for arresting this paralysis. Fara- dization of the muscles of the tongue, soft palate, and lips, alone succeeded in temporarily restoring slight contractility to these enfeebled muscles, so that the patient was constantly begging for electricity to be used. During the last month of his existence, deglutition became more and more difficult. As he could only use his left hand, a paste made with bread and wine, of semi-liquid consistency, had to be poured into his mouth. He first opened his mouth, letting his head fall backwards so as to receive the food, and then closing his mouth immediately with his left hand in order to keep the paste in, he bent his head forwards, making at the same time repeated efforts to swallow. In spite of this contrivance, it sometimes happened that the food came back through the mouth and nostrils. Subse- quently, liquids alone could be swallowed, and the patient died at last of starvation fever, with rigidity of the limbs on the right side and paralysis of the bladder and rectum. At the post-mortem examination, atrophy of the roots of the hypoglossal nerve was found, together with increased consistency of the medulla ob- longata. At No. 19, in the same ward, we had an opportunity of studying another example of this form of paralysis. B , a gardener, aged 62, after having enjoyed excellent health pre- viously, and having never committed any excess, or been exposed to any of those poisonous influences which sometimes bring on paralysis, fell ill in February, 1862. He was suddenly seized with fever and delirium, which lasted three or four days only. He was convalescent for a short time, and he seemed cured, when his attention was drawn by his friends to a slight nasal resonance of his voice, and he noticed himself that he had some diffi- culty in pronouncing words beginning with the letters r, c, k, q, so that the 912 ON GLOSSO-LARYNGEAL PARALYSIS. tongue was already somewhat embarrassed. The following month, at the end of a day's work in the sun, he suddenly felt weakness of the right leg and arm, without any impairment of intellect. He remarked at the same time also, that his food collected between his teeth and cheeks, and that at intervals he was obliged to wipe his lips, which were wet with the escaping saliva. His appetite was good, and all his functions were performed with regularity. On June 12th, 1862, B was admitted into the Hotel-Dieu, under Dr. Empis, who was then acting as Professor Rostan's substitute. He was still able to relate the accession and the course of his complaint, although his lips were manifestly paralyzed. He could not pronounce the letters o and u, and he dribbled when he talked. His face was natural when at rest; but when he laughed, the angles of his mouth were strongly pulled upwards and outwards, and his mouth remained half-open, so that he was obliged to use his hands in order to bring his lips together. The tongue seemed to be fixed behind the lower row of teeth, by which it was indented, and it was with great difficulty protruded outwards and forwards. Its apex, which deviated a little to the right, could not be raised to the upper incisors, or above the lower molars. The articulation of certain words, however, and deglutition were still possible, but with very manifest trouble and difficulty. The right arm and leg were weak; the left ankle could not be flexed, and the sensibility of the left side was diminished. The progress of the disease was rapid and continuous. When in Septem- ber, B came under my care, he could no longer pronounce the letters c, p, t; but he could still articulate the consonants b, d, I, m, n. He swal- lowed his saliva with difficulty, and he already complained of a sense of constriction in the throqt. He often passed his fingers down the back of his mouth, as if he wished to extract some foreign body which interfered with deglutition. His intellect was perfectly clear, and if he had great difficulty in uttering sounds, his physiognomy showed that he understood perfectly all the questions that were put to him. Even then, however, the lower part of his faee was not long before it became motionless, whilst the upper part, and more particularly the eyelids and forehead, retained all their mobility. The feebleness of the sounds uttered by the patient was remarkable. Indeed, when his chest was exposed, one was struck with the weakness of his respiration. There was scarcely any oscillation of the walls of his chest during inspiration and expiration; the lungs took in and expelled very little air; expiration was feeble and slow. This was one of the reasons why the sounds were feeble. Besides, if he was asked to retain the air contained in his chest, he was unable to do so, and the air continued to escape slowly. The glottis remained always open, so that the air passed to and fro through the larynx, almost as through an inert tube. The glottis seemed to have lost the greater part of its active tension, and could no longer, under the control of the will, vibrate like strings, or like the membranes of a reed instrument. There was not only loss of speech, but complete aphonia also, and it was only by dint of considerable exertion that he could feebly uttei* the sound of a. The above details have already shown you how feebly respiration is carried on in such cases. In the man at No. 19 this diffi- culty of breathing was still more increased on his catching a cold. At such times he could not always cough, for he was not strong enough to expel rapidly the air contained within his chest, so that he could not easily clear his bronchial tubes and larynx of the accumulating mucus. I was very much afraid lest the dyspnoea, which was very marked already, should go on increasing, in which case the patient would be choked through ON GLOSSO-LARYNGEAL PARALYSIS. 913 accumulation of the bronchial mucus. The muscles of the chest were there- fore electrified every day, and, by his gestures, B expressed how much better he felt then. The dyspnoea became less intense, and for several hours afterwards the supplementary muscles of respiration, the sterno-mas- toidei, the trapezii, and scaleni, ceased their rhythmical contractions, which had assisted the intercostal muscles and the diaphragm. Every day, how- ever, until the cold got well, electricity had to be used. The muscles of respiration were not the only ones affected, for the mus- cles of the neck were very feeble too. In fact, B could not touch his chest sharply with his chin, of keep his head forcibly extended.. The cer- vical muscles, therefore, the trapezii, and sterno-mastoidei, shared in the' weakness of the thoracic muscles, and perhaps also were the scaleni and the deep muscles of the anterior and posterior cervical regions similarly affected. The patient had some difficulty in carrying his head' up, and he had to pay d certain degree of attention in order to keep it in equilib- rium. Deglutition soon became still more difficult. The food, although per- fectly masticated, passed with great difficulty, or with feeble jerks, from the cavity of the mouth into the pharynx. B then applied his hands over his mouth and cheeks in order to assist the contractions of the orbicularis oris and buccinators. The movement of elevation of the base of the tongue seemed very limited, and when the food reached the pharynx it was some- times rejected through the nose. Liquids also were swallowed badly; they sometimes got into the larynx, in spite of the aryteno-epiglottidean folds, and brought on fits of coughing made up of short jerks.. The circulation, both centric and peripheral, presented no serious modi- fication. The pulse at the wrist was a little more frequent than normal- 92 in the minute; the heart's action was powerful and regular. Until then, there was no paralysis of the bladder and rectum. In a short time, however, the general debility increased rapidly.. The patient, who used to walk, although with difficulty, dragging his legs and resting on the back of a chair which he pushed before him, found himself incapa- ble of leaving his bed. His breathing became slow and incomplete-, deglu- tition more and more difficult, his facies altered, and death took place quietly and without any struggles, the patient having only a moment before made signs to thank the attendants for helping him to place his head down on his pillow. Post-mortem Examination.-No fatty degeneration of the diaphragm, although its fibres looked pale. No portion of the muscular system pre- sented that beautiful red color which is prpper to it, and the extreme fria- bility of the muscles of the right leg, especially of the peroneus longus, tibialis anticus, and quadriceps femoris, contrasted with the almost normal resistance of the corresponding muscles of the left side. Besides, the fria- ble, softened muscles were of a reddish-yellow color, and manifestly under- going commencing fatty degeneration, a fact about which microscopical examination left no doubt. The muscles of the face and the orbicularis oris,, although not well de- veloped, were not altered. The intrinsic and' extrinsic muscles of the tongue were normal, as well as the buccinators, the muscles of the soft palate, of the pharynx, the larynx, and the neck. The calvarium was very thin. The dura mater looked thickened-; the pia mater wTas oedematous and injected, but could be removed without tear- ing away the cerebral tissue. The gray matter was of good consistency and unaltered; the white matter was of a cafe au lait color, and presented- very distinct red points. Several portions of the circumference of the left vol. i.-58 914 ON GLOSSO-LARYNGEAL PARALYSIS. corpus striatum were stained of an amber-red color, which was apparently due to small hemorrhagic clots of old date. These parts, when examined under the microscope with a power of 250 diameters, were seen to contain hsematin in a state of fine powder, and granular deposits of a brownish-red tint. The optic and olfactory nerves v7ere of normal color and consistency. The motor oculi had a grayish tint at its origin, but the fourth nerve was sound. The fifth and sixth nerves could not be examined at their origins. The "facial was flattened at its origin, on both sides, but was not affected in other respects. The roots of the pneumogastric were atrophied, but the glosso-pharyngeal nerves were healthy. There was marked hypersemia of the cerebellum. The floor of the fourth ventricle presented a plexiform arrangement of vessels. The roots of the right hypoglossal nerve were so atrophied, that they re- sembled filaments of congested cellular tissue. When examined under the microscope, they were found to contain deposits of pink, brownish-red, and greenish hsematin. The nerve-tubes were few in number, collapsed in parts, with .a granular cylinder-axis, and apparently softening myeline. The roots of the left hypoglossal were not examined, because they had been torn from the bulb when the spinal cord was removed. The roots of the spinal accessory were on both sides small. The neuri- lemma predominated, especially on the left side, and all the roots of the nerve, both those from the medulla and those from the spinal cord itself, were of a grayish color. The microscope detected an increase of vessels in them ; the capillaries of the neurilemma were turgescent, the neurilemma itself thickened, and consequently the nerve-tubes of the roots were dis- tinguished with difficulty. In the midst of the elements of the neurilemma there was seen a fatty substance, irregularly scattered in granules. The fibres of the connective tissue were markedly developed, and were mixed up with a good many elastic fibres. The dura mater for the upper third of the cervical portion was thickened, congested, and of an ashy-gray color. The .anterior spinal roots were atrophied, especially on the left side, near the roots of the spinal accessory. In that part, the roots of the last nerve seemed to be reduced to a band of connective tissue, whilst the antero- lateral columns, in the part which gives attachment to the motor roots, were of the same color and had the same congested appearance as the posterior columns present in cases of locomotor ataxy. The roots of the right spinal accessory nerve were less atrophied, but had to some extent the same color, and were as congested as the roots of the opposite side. A good many of the anterior spinal roots presented a rela- tive diminution of size, and a markedly congested condition analogous to what has been noted in general progressive muscular atrophy. Sections of the spinal cord, made at different parts, were examined, and marked hypersemia of the upper cervical portion was found. The gray substance of the cord was of a deeper color and was harder than natural, showing a relative sclerosis of the cord. Are you not struck in this case, gentlemen, with the existence of general hypersemia of the cerebro-spinal axis, coupled with relative atrophy of the greater number of cranial and spinal motor nerves ? For these pathological lesions resemble those which have been described by Professor Cruveilhier in progressive muscular atrophy, and by Dr. Dumenil (de Rouen) in a complex case of paralysis of the tongue and general muscular atrophy. Let us now proceed to analyze Dr. case, and the one reported in Dr. Duchenne's memoir. Dr. Dumenil reports his case under the following heading: Atrophy of ON GLOSSO-LARYNGEAL PARALYSIS. 915 t he hypoglossal, facial, and spinal accessory nerves : complete motor paralysis of the tongue, incomplete of the face. Integrity of the muscles of the tongue and face. Atrophy of the anterior spinal roots: incomplete paralysis of the limbs, incipient muscular atrophy.-That atrophy of motor nerves should cause paralysis of the muscles to which they are distributed, is perfectly in accordance with physiological notions. But how is it that the atrophy of the spinal roots caused atrophic degeneration of the muscles supplied by them, whilst the atrophy of the cranial nerves and their roots did not pro- duce the same effect on the muscles of the tongue and face ? Dr. Dumenil at first thought that this difference might be owing to the fact "that motor cranial nerves do not have the same influence on the nutrition of muscles as the anterior roots of spinal nerves." But Dr. Duchenne having reminded Dr. Dumenil that in Professor Cruveilhier's case there had been noted atrophic degeneration of the tongue as well as atrophy of the hypoglossal nerve, Dr. Dumenil had to give up his hypothesis, and, after fresh re- searches, he was perhaps the first to express the opinion that the impair- ment in the nutrition of the muscle was a consequence of a lesion of the sympathetic. However this may be, Dr. Dumenil's patient was afflicted with a paralysis of the tongue, the muscles of the face and limbs, which was due to atrophy of motor, cranial, and spinal roots. How can an individual be said to suffer from two associated diseases, namely, progressive muscular atrophy and glosso-laryngeal paralysis, when the anatomical lesion is one and the same? We shall discuss this question by and by. A case communicated by Dr. Costilhes to the Medical Society of Paris, in 1860, suggests the same reflections, since there was general muscular de- bility as well as symptoms of glosso-laryngeal paralysis. However interest- ing that case may be, I shall now proceed to comment on the eighth case of Dr. Duchenne's memoir, which he calls : Progressive paralysis of the tongue, the soft palate and lips, coinciding xvith progressive fatty muscular atrophy limited to a few muscles of the upper extremities. The patient stated that the disease had set in with weakness of the move- ments of the right arm. Dr. Duchenne found atrophy of the muscles of the right hand, and also commencing atrophy of the left hand, the trapezii, and many other muscles of the trunk and limbs. Whilst questioning the patient, he noticed besides a marked defect of articulation, a circumstance which surprised him at the onset of progressive muscular atrophy, because, in such cases, atrophy of the tongue is only observed at the close of the disease. Direct examination of the tongue, however, showed that the organ was not atrophied, but merely paralyzed, as were also the orbicularis oris and the muscles of the soft palate. The history of the case could not be completed, as the patient left off coming to Dr. Duchenne. In this case, says Dr. Duchenne, there were two different diseases, namely, muscular atrophy of the limbs without paralysis, and paralysis of the tongue without atrophy. " Chance alone, a mere coincidence," adds the learned investigator, " had brought together these two distinct morbid va- rieties," both in the patient he saw himself in 1858, and in the one seen by Dr. Dumenil in 1859. I may be allowed to observe, however, that when Dr. Duchenne made this positive assertion, there was only on record the post-mortem examin- ation made by Dr. Dumfinil, which established the existence of an identical lesion in the roots of the hypoglossal nerve and the anterior spinal roots. Since then, a post-mortem examination, made at my request by Dr. Luys and M. Dumontpallier, in presence of Dr. Duchenne himself, has shown that glosso-laryngeal paralysis and progressive muscular atrophy are at- tended with the same nerve-lesions, .namely, atrophy of motor roots, both 916 ON GLOSSO-LARYNGEAL PARALYSIS. cranial and spinal. Besides, clinical observation has proved to me, in all the cases which I have seen, that in patients suffering from glosso-laryngeal paralysis there is a tendency in the paralysis to become general. It is very probable, therefore, that there is more than a mere chance coincidence in all these cases. I do not wish to insist further on this point, and I hasten to add that Dr. Duchenne was right in giving a distinct description of these two morbid conditions, because the progress of the disease is different, and the termin- ation always rapidly fatal in glosso-laryngeal paralysis. But in my opinion these morbid states are only varieties of a paralysis depending on an affec- tion of the spinal cord or medulla oblongata, the chief anatomical expression of which seems always to consist in an atrophy of the motor roots. Let us now return to the general study of the four cases of glosso-laryn- geal paralysis which I have related to you. It is not difficult, if we keep in mind the principal symptoms observed in each of these cases, to give a broad sketch of this disease, the origin, progress, and termination of which are so very characteristic, that we meet with no other identical affection in the whole range of nosology. When the patient comes to us for advice, the disease has already made great progress, and all its characters are well marked. On carefully ques- tioning him, however, it is found that the first circumstance which attracted his notice was slight embarrassment of speech. Soon afterwards, he ob- served that his tongue was not equally supple, and that his utterance became thicker and thicker. His food then lodged at times between his teeth and cheeks; the tip of his tongue being awkward and incapable of doing it, he had to use his fingers to replace the food on his tongue. The pronunciation of certain words was marked by a nasal resonance; the vowels o and u could not be pronounced, because the contractility of the orbicular muscle, which is indispensable for this, had diminished, and there was occasional dribbling of saliva when the head was inclined. Now, do not these facts point to an incipient paralysis of the tongue, the soft palate, and orbicularis oris ? By degrees, however, the paralysis makes continued progress; the tongue remains fixed as it were behind the lower teeth ; its apex and its base are equally motionless; not a single word can be articulated. The first stage of deglutition has become almost com- pletely impossible, and the patient has recourse to all kinds of stratagems for getting his food into the pharynx. He tries to help the orbicularis oris and the buccinator with his hands, and applying them over his mouth and cheeks, he makes repeated and considerable efforts in order to get his food to pass into the pharynx, and yet he takes great care to chew well what he eats, and to facilitate its gliding down by drinking and throwing his head backwards. At last he sometimes succeeds in swallowing, but at other times the co-ordinate contraction of the pharyngeal constrictors being at fault, only a small quantity of food gets into the (esophagus, whilst the greater portion is thrown up through the mouth and nostrils, the posterior aper- tures of the latter having remained open through the paralysis of the soft palate. These unfortunate patients are of course a considerable time over their meals, for their appetite remains excellent. Liquids also are often swal- lowed with great difficulty. Oftentimes small portions of food pass into the larynx, and then to the horrible torture of not being able to swallow is superadded extreme difficulty of coughing in order to get rid of the food which has passed into the larynx and trachea. The anxiety is extreme ; at last, after frequent fits of a small jerking cough, the patient gets calm ON GLOSSO-LARYNGEAL PARALYSIS. 917 again. Hence it may be seen that he is, at every moment, in imminent danger of death by suffocation. When the paralysis has advanced so far, excessive weakness of the respi- ratory movements may be easily discovered. The walls of the chest scarcely move, and the diaphragm itself sometimes shares in this apparent immo- bility. At this period of the disease the auxiliary muscles of respiration have also become powerless, and superior thoracic breathing is impossible. If the patient be asked to blow out a candle, he collects all his strength, and yet the flame is scarcely agitated as he blows on it. This is not only owing to a division of the column of air which is expired, and its passing at the same time through the mouth and nostrils, nor merely to the inability of the patient to contract the buccinators and orbicularis oris in order to guide the column of air, but it is chiefly due to the small volume of this column, and to the paralysis of the bellows, namely, the walls of the chest. If such patients be attacked with bronchitis, they are in danger of quickly dying of asphyxia, because they can no longer cough vigorously, and thus expectorate the bronchial mucus. The pulse sometimes becomes frequent without any fever supervening, and I shall by and by inquire into the physiological reason of this fre- quency of the heart's action. As a rule, no pain is complained of, but in some cases pain is felt in the occipital and upper part of the cervical region. Sensibility is everywhere normal: those very muscles which are paralyzed retain the property of contracting under the influence of electricity, and irritation of the mucous membrane of the soft palate produces contraction of the velum through a reflex action. As the general debility makes constant progress, however, the patients drag themselves along with difficulty, resting on the arm or back of a chair, which they push slowly before them. They next refuse to get up, and prefer to sit up in bed, with the upper part of their body propped up, their head resting on pillows, and inclined to one side, in order to let the saliva which they are unable to swallow run out of their mouth. Their sleep is often disturbed by paroxysms of suffocation, probably due to the passage of the saliva or of the pharyngeal mucus into the larynx. If death does not take place in one of these paroxysms, it seems to be caused by an arrest of the contractions of the heart, is unaccompanied by pain or any noise, and occurs suddenly. Such, gentlemen, is the course usually run by this malady, but it is some- times accompanied by other morbid phenomena-by paralysis, for example, either of the upper and lower limbs, or of some muscles only of these different segments of the body. Such cases are merely instances of the extension of the disease. But in others you may observe genuine compli- cations, such as atrophy and fatty degeneration of the muscles, hemiplegia even, due to there having occurred hemorrhage or softening at a period anterior to the disease. In most cases, however, the patients die without presenting any other anatomical lesions besides those which are directly dependent on the disease itself. Let us now inquire whether the alterations found after death can explain the symptoms observed at the bedside. The first post-mortem examination which I made was entirely negative as regards the anatomical lesion; perhaps, however, because it was incomplete. In the second case there was found very marked atrophy of the roots of the hypoglossal nerve, without any alteration of the muscular fibres them- selves. The medulla oblongata was apparently also of greater consistency than normal. 918 ON GLOSSO-LARYNGEAL PARALYSIS. In the third case, I found well-marked thickening and gray discoloration of the dura mater, on a level with the medulla oblongata, and as far down as the roots of the fourth cervical pair. This thickening was due to a con- siderable increase in the amount of fibres of connective and fibro-elastic tissue, and seemed to result from a chronic congestive process, as shown by the great number of capillaries and of deposits of hsematin external to them. , The roots of the hypoglossal and spinal accessory nerves were atrophied, and reduced in several places to the neurilemma; and at the spot where the spinal accessory was in contact with the dura mater there was adhesion of the neurilemma to the fibrous envelope of the cord, and a deposit of a nucleus of connective tissue of the size of a pea. A good many motor roots in the cervical region were thinner than natural, from partial disappearance of the nerve-tubes. With the aid of the microscope, the neurilemma was seen to preponderate everywhere over the nerve-tissue properly so called, and notable hypersemia could be detected everywhere, also together with grayish discoloration of the neurilemma. The cord itself, and the upper part of the anterior columns, was as congested and of the same color as the posterior columns are found to be in cases of progressive locomotor ataxy. The fibres of the palsied muscles of the tongue, soft palate, lips, chin, and cheek, &c., were unaltered. As to the diminution in size of the mus- cles of the right leg, and their condition of incipient fatty degeneration, they need only be mentioned. From the study of these three cases it follows, that in this complaint the paralysis is due to an alteration of the motor roots which supply the affected muscles, these latter in most cases presenting no change of volume and structure. The complete paralysis of the tongue is accounted for by the general atrophy and complete disappearance, in some places, of the roots of the hy- poglossal nerve. In Dr. Dumenil's case, the alteration was not confined to the roots alone, for the trunk itself and all the branches of the nerve were of a grayish color and notably atrophied. The lingual nerve, on the con- trary, which is a branch of the sensory portion of the fifth cranial pair, was normal, as well as the glosso-pharyngeal, so that the healthy condition of these nerves accounted for the preservation of the general and special sensi- bility of the surface of the tongue. Electro-muscular sensibility had been present in the beginning, but had diminished by degrees, and the nervous influence which reached the muscle being feeble only, electricity gave little relief to the patients. Thus was explained, first the difficulty, and next the almost complete inability to swallow. The embarrassment of speech and the modifications in the resonance of the voice are explained by the paralysis of the muscles of the tongue, soft palate, lips, and chin. Perhaps an alteration of the deep roots of the facial nerve would have been detected, had the examination been carried so far; but in default of this Dr. Dumenil found structural alterations of the trunk of the facial and its branches, which accounted for the loss of contractility of the orbicularis oris, which is indispensable for the pronunciation of the so-called labials, and particularly of the letters o and u. The alteration of the facial also accounted for the paralysis of the buccinators, the muscles of the soft palate and chin, which are supplied by this nerve. We found, as you remember, grave lesions in the bulbous and spinal por- tions of the spinal accessory. Our attention was directed also to the pneu- mogastric, the roots of which were atrophied. The anatomical facts which we have mentioned account perfectly, therefore, for the principal phenomena ON GLOSSO-LARYNGEAL PARALYSIS. 919 which have been observed, and agree entirely with the results of physio- logical experiment. The patient, however, had not only lost the faculty of speech, but had also become affected with nearly complete aphonia. This phenomenon de- pended on two causes, namely, paralysis of the muscles of the larynx and paralysis of the thoracic muscles. Indeed, physiological experiments prove that when the spinal accessory is torn off at its roots, aphonia is brought on through the relaxation of the vocal cords, which therefore become incapable of producing vocal sounds. On the other hand, Longet and Claude Ber- nard have shown that the section of both inferior laryngeal nerves causes occlusion of the glottis during inspiration, and consequently death by asphyxia. This occlusion of the glottis can explain the sudden death of the patient, with this reservation, however, that in old persons as well as in old animals, the complete occlusion of the glottis is not probable, on account of the considerable development of the anterior processes of the arytenoid cartilages, which leave between them an interval, open at all times, and called by Longet the respiratory glottis. The absence of tension of the glottis explains the feebleness of the voice ; whilst, through the spinal accessory being diseased, there can be no pro- longed voluntary expiration, so as to sustain the voice, and when the pa- tient, therefore, makes a great effort to utter a sound, he only succeeds in producing a short and low grunt. In order to explain the feebleness of the voice, wTe must also keep in mind the weakness of the thoracic muscles, which scarcely inspire, and have consequently little to expire; and if at rare intervals a deep inspiration is made, perhaps it is to be ascribed to an affection of the pneumogastric. For is it not known that, whilst accelerating the heart's action, division of the vagus slackens respiration, and that the animal which is the subject of the experiment makes deeper inspirations at intervals? The feeble con- traction of the diaphragm is explained by the lesion of the motor spinal roots from which the phrenic derives its nervous influence. We thus see that physiological facts are in complete accordance with pathological observation to account for the symptoms or functional dis- turbances met with in this disease, namely, feebleness of the voice, slacken- ing of the respiration, and death by suffocation or asphyxia. All these phenomena are the results of disease of the spinal accessory nerve. The physiology of that nerve gives us also an explanation of other phe- nomena. " If to an animal in which the spinal accessory nerves have been torn off," says Claude Bernard, " appropriate food be thrown, it rushes on it voraciously; but it soon gets less ardent, and eating more slowly, stops and lifts up its head every time it swallows. If it be suddenly disturbed at that instant, a sort of cough or of sneezing is sometimes produced, as if por- tions of food had a tendency t'o pass into the trachea." Note, gentlemen, that the first stage of deglutition was normal in such cases, and that there had been no lesion of the hypoglossal nerve. This impediment in the second stage of deglutition is explained by the paralysis of the pharyngeal branch of the spinal accessory, but there is no complete paralysis of the pharynx, because its muscles receive other motor branches from the pharyngeal plexus. Have we not, indeed, found in our cases that the food often got into the larynx, and that the sensibility of this organ, which was unimpaired, then caused reflex contractions of its muscles, often, however, insufficient to ex- pel the foreign body ? These phenomena are analogous to those observed in animals after the spinal accessory nerves have been torn off, and in whose 920 ON GLOSSO-LARYNGEAL PARALYSIS. trachea and bronchial tubes, and upper lobe of the lungs even, portions of food may be found. Sensibility, therefore, is preserved in the larynx as well as in the tongue and palate. The sensibility of the larynx, as you well know, depends on the superior laryngeal nerve, which supplies only one laryngeal muscle, the crico-thyroid. The use of this muscle is to swing the thyroid cartilage on the cricoid, and thus to tighten the glottis. The superior laryngeal is, therefore, partly a motor nerve, and, indeed, the experiments of Professor Claude Bernard have led him to believe that, although almost exclusively sensitive, the pneumogastric had still the power of exciting contractions. This motor power of the nerve is special, and might be termed respiratory; because, after the spinal accessory has been destroyed, and the functions of the larynx, as the organ of sound, abolished, respiration goes on when the animal is at rest; but if the pneumogastric be torn, or the recurrent laryn- geal nerve be divided, the dilatation of the glottis is immediately replaced by a flaccid condition, and the animal dies of suffocation brought on by the approximation of the lips of the glottis during inspiration. If the spinal accessory be an undoubted respiratory nerve, acting volun- tarily on the muscles of the larynx and the supplementary muscles of res- piration, the pneumogastric is an involuntary nerve, a nerve of organic life, which presides in the larynx as in the lungs over the maintenance of the respiratory functions. It is from the pneumogastric, then, that the laryngeal, tracheal, and bronchial mucous membrane, as well as the crico- thyroid muscles and the muscular fibres of the bronchial tubes, derive their sensory and motor properties ; and this fact explains how oxygenation of the blood continues in cases of glosso-laryngeal paralysis, in spite of the lesion of the spinal accessory nerves and the anterior roots of the cervical and thoracic spinal nerves. That the vocal is not dependent on the respi- ratory larynx is again proved by comparative anatomy, for birds have a distinct vocal as well as a respiratory larynx. Lastly, is it not remarkable that in the complaint which we are now studying, the lesions at the onset are almost exclusively confined to the muscles of the life of relation, as shown by an alteration of the voice, of articulation, of expression, and phys- iognomy? while it is only secondarily that the tongue, the soft palate, and the pharynx, become affected as organs of deglutition and muscles of organic life. Later, however, and sometimes simultaneously with, or even before the setting in of the impediment of speech, paralysis of some of the muscles of animal life is observed, as in the cases recorded by Drs. Du- chenne and Dumenil, and in the cases which fell under my own observa- tion. The healthy condition of the pneumogastric in some cases, and the slight degree in which it is affected in others, explain how it is that the other functions over which this nerve presides remain nearly normal. Thus, in no case was there paralysis of the oesophagus, or of the stomach ; and se- cretion of the gastric juice, and gastric absorption, seemed to continue nor- mally. As to the general debility and the wasting occurring during the last days of the patient's life, they are sufficiently accounted for, I believe, by the inability to swallow, by the patient's confinement to bed, and per- haps by the considerable loss of saliva through the opened mouth. I have described to you, gentlemen, the chief symptoms of glosso-laryn- geal paralysis, the post-mortem appearances met with, and I have attempted an explanation of the symptoms, that is to say, the pathological physiology of the disease, grounding my opinions on the anatomical lesions found, and on the learned experimental researches of physiologists. It now remains for me, in order to complete the description of this complaint, to draw ON GLOSSO-LARYNGEAL PARALYSIS. 921 your attention to its course, its modes of termination, and its differential diagnosis. At the beginning of this conference I told you that glosso-laryngeal paralysis always terminated in death; and I do not believe that a single case of this disease is on record in which its progress has been arrested even for a few months. At the outset, however, the progress of the malady may be somewhat slow. The patient has an embarrassment in his speech for three, four, five, or six months, and he has some difficulty in keeping his saliva in his mouth ; but as soon as deglutition becomes difficult, the disease makes rapid progress in most cases, and life is soon gravely compro- mised. The disease, which had at first been apparently confined to the inferior segment of the face, and to the tongue, soon invades the larynx, the walls of the chest, and the diaphragm. The respiration, it is true, seems to be carried on with regularity still, but each inspiration is feeble, the patient seeming then to breathe after the manner of hibernating animals; and this incomplete respiration must, sooner or later, cause appreciable modifications in calorification and the oxygenation of the blood. In order to make the respiratory feebleness very apparent, it is only necessary to ask the patient to make some effort, when not only is feebleness observed, but also a want of harmony in the performance of the respiratory act. The patient can no longer, take in air enough to blow out a candle ; he can no longer keep up the amount of effort necessary to allow him to get into bed, or to walk a little briskly ; still less can he go up stairs, for the least effort makes him pant for breath, and compels him to stop suddenly. He is unable to make an effort, because, owing to the paralysis of the spinal accessory, the aperture of the glottis remains wide open, and because the walls of the chest being no longer supported by the sterno-mastoid and trapezii muscles, which are now powerless, fall back on the lungs. From the inability of the inspiratory muscles to store up air within the lungs result the feebleness of the voice, and the disorders which must follow on deficient oxygenation of the blood, rendered sometimes still more imperfect by paralysis of the diaphragm. Condemned to a nearly complete immobility, the patient is almost always in bed or sitting in a chair. For the same reason that he cannot walk, he cannot make the effort of coughing and expectorating, that is to say, he cannot make with his thoracic bellows the sudden inspiratory movements that are requisite for detaching the mucus contained in his bronchi in order to reject them by a violent expiration. This impairment of the chest-walls is a grave prognostic sign, because the least attack of bronchitis may, by causing engorgement of the lungs, kill the patient by asphyxia. Bronchitis, however, is not always a proximate cause of death, and indeed you saw that the patient at No. 19, in St. Agnes Ward, did not die of the bronchitis which attacked him. We must admit, in such cases, that through a special organic contractility, the air-passages gradually rid themselves of their mucus by expelling it into the trachea and larynx. We almost have a proof of this hypothesis in the laryngeal embarrassment complained of by the patient in such cases. He is seen to make feeble efforts in his attempts to cough and clear his larynx; but he is unable to expectorate, and if the mucus be not immediately swallowed, it sojourns a variable time in the pharynx. In order to clear his pharynx, the patient again tries to cough, whilst, by passing his finger down to the back of his mouth, he produces a tendency to vomiting, through which the mucus is brought up as far as the base of his tongue, where he can seize it with his fingers. In the description which I gave you of the disease, I did not lay great 922 ON GLOSSO-LARYNGEAL PARALYSIS. stress on the dribbling of saliva out of the mouth, a circumstance which is constantly observed, and which persists until the death of the patient. I did not speak to you either of the grave consequences which had been at- tributed to this prolonged loss of saliva, because there are on record cases of salivary fistula which, in man, and in horses also, did not bring on failure of strength or marked wasting. Dr. Vella, however, a professor at the University of Modena, and Dr. Duchenne, have ascribed to this circumstance some share in the general debility observed in these cases. But the progressive course of the paralysis of the muscles primarily at- tacked, and the implication of other portions of the muscular system, taken together with the pathological lesions observed, suffice to show the gravity of such a paralysis. The almost complete dysphagia, and the extreme fre- quency of attacks of choking caused by the passage of food into the larynx, give rise to fears that the amount of food taken will prove insufficient, and that death by asphyxia is ever imminent. Indeed, the patients die of star- vation, and more frequently through being choked. Now when death is not preceded by any symptoms of pain or by spasms, has one a right to suppose that syncope was a proximate cause of the fatal termination ? The patient at No. 19, in St. Agnes Ward, probably died from a sudden arrest of the heart's action, and the post-mortem examination showed that the cavities of the heart were distended by large clots of blood. There is another mode of fatal termination, by asphyxia, identical with that observed in cases of the general paralysis of the insane, and which is due to an arrest of the food on a level with the upper orifice of the oesopha- gus. This accident scarcely ever happens except at a period when the patient can still swallow semi-solid substances, whilst in the last stage of the disease he cannot accomplish this. From this observation may be deduced a thera- peutic indication, namely, that life may still be prolonged for several days, or months, if the morsel of food be extracted in time. And, as you may recollect, the life of the woman lying at No. 29, in the St. Bernard Ward, was thus prolonged. Now, are we in a position, with the aid of the characters of this disease, to distinguish it from any other local or general paralysis? The general paralysis of the insane sets in, it is true, with an embarrass- ment of the tongue; but there may be noticed, at the same time, slight con- vulsive trembling of the lips, and in most cases delirium is observed from the beginning, together with a fixed stare, which is never met with in the patients whose cases I related to you. Besides, in glosso-laryngeal paralysis the intellect is always perfectly clear, and the patients soon find out the gravity of their complaint; whereas this is not the case in the paralysis of the insane. Again, in this last affection, if sooner or later general feebleness of the muscular contractility be observed, in no case does this paralysis affect specially the muscles of the soft palate, nor is there ever dribbling of the saliva, whilst from the beginning the practitioner is led, on account of the failure of the intelligence, to locate the disease in the brain. We need not stop to diagnose hemiplegia from this form of paralysis, be- cause, if in our patients we often found paralysis of one of the upper or lower limbs, we at the same time discovered disorders of motility in the muscles of the tongue, the soft palate, and the lips, which, taken as a whole, and from the symmetry of their manifestations, did not suggest the idea of a cerebral hemiplegia. An affection which is of very rare occurrence, namely, double facial paralysis, might be confounded with this form of disease, and the mistake would be excusable. Indeed, in double facial paralysis the muscles of the lips are motionless, and the patient has consequently a difficulty in pro- ON GLOSSO-LARYNGEAL PARALYSIS. 923 nouncing labials. On the other hand, if both facial nerves be diseased high up in the aqueductus fallopii, the consequence will be that the pa- tient's voice will have a nasal whine, owing to the paralysis of the soft palate. Let us add again that, through his inability to contract the isth- mus faucium, he will have some difficulty in swallowing. These symptoms resemble very much those of glosso-laryngeal paralysis, and yet these two diseases may be distinguished from one another. For in the former the hypoglossal nerve is not affected, and the tongue therefore is not impeded in its movements. In the latter, on the contrary, these movements are deeply interfered with. Again, in double facial paralysis all the muscles of the face are paralyzed, and whatever moral emotions be felt by the patient, his face preserves the immobility of marble. It seems, as Dr. Duchenne has felicitously expressed it, as if the patient laughed or cried from behind a mask. In glosso-laryngeal paralysis, on the contrary, the lower part of the face alone remains motionless, and if the patient laughs, he laughs with his eyes, and moves his zygomatici and the muscles of his forehead. If he weeps, on the other hand, the upper part of his face is thrown into contraction and expresses true grief. In double facial paral- ysis, deglutition is scarcely affected, and it is only the articulation of the letters o and u which becomes difficult. Glosso-laryngeal paralysis might possibly, in the beginning, when there is yet no great impairment of motility in the tongue and the orbicularis oris, be confounded with diphtheritic paralysis restricted to the soft palate, or implicating other muscles as well. But the fact of there having been a previous attack of diphtheritic angina, or a previous manifestation of diph- theria in some part of the organism, suggests the nature of the case, and the diagnosis will soon be confirmed by the isolated localization of the paralysis in the soft palate, or in cases when it becomes general, by other functional disorders which are never observed in glosso-laryngeal paralysis, namely, modifications of the general sensibility and special disorders of vision. In the cases when progressive muscular atrophy begins in the tongue, and next attacks the soft palate and the orbicularis oris simultaneously, or posteriorly affecting the muscles of the limbs and trunk, a mistake might be made. Progressive muscular atrophy, rarely, however, begins in that way in the adult; and even were it to do so, a careful examination would soon disclose well-marked muscular atrophy of some other -part of the body, in most cases in the thenar and hypothenar eminences, the interossei muscles of the hand, &c. Besides-and Dr. Duchenne lays .great stress on this fact-in glosso-laryngeal paralysis the paralysis sets in at once, un- accompanied by atrophy; whilst in progressive muscular atrophy, the atrophy is primary, and paralysis supervenes only after the destruction of the contractile fibres. There are on record some very interesting cases, which Dr. Duchenne has termed cases of associated diseases, in which progressive fatty muscular atrophy affecting the limbs is met with concurrently with paralysis, with- out atrophy, of the muscles of the tongue, the soft palate, and the lips.* Dr. Duchenne thinks that there are two distinct diseases associated in such cases. But must we entirely concur in this opinion ? When in the same individual you find, on the one hand, progressive paralysis of the tongue without any atrophy of the organ, and, on the other hand, progres- * Vide Case VIII of Dr. Duchenne's memoir, and Dr. Dumenil's case, Gaz. Hebd., 1859 and 1861. 924 ON GLOSSO-LARYNGEAL PARALYSIS. sive muscular atrophy in other parts of the body, will you not incline to the opinion that these two morbid conditions are dependent on the same organic lesion ? Lastly, if pathological anatomy proves to you that the roots of the hypoglossal and the spinal motor roots have undergone the same alterations, can you refuse to believe that the same anatomical nerve-lesion has produced in one part paralysis of the tongue without atrophy, and in another part paralysis with fatty degeneration of certain muscles ? Dissection has shown that, in glosso-laryngeal paralysis, the lesion was primarily seated in the upper portion of the cord and in the motor roots. We saw that, in that part only, had the dura mater acquired considerable thickness, and that it presented a highly vascular condition, with grayish discoloration, pointing to congestion of ancient date. We saw the roots of the spinal accessory nerve reduced to their neurilemma, and we noted in- cipient atrophy of the cervical roots. These anatomical details sufficiently indicate the gravity of glosso-laryn- geal paralysis. But does it follow that, in no case, is the physician able to help the patient? It is plain that in the two first stages of the disease the physician can, I do not say arrest completely the progress of the disease, but at least prevent it from lieing so very rapid, and can relieve for some time. He is still able, with only one remedy, namely, faradization of the affected muscles, to restore to them a transient contractility, and thus ob- tain that deglutition be accomplished with a little less difficulty and pain, and consequently that food be taken more regularly and effectually. He may, by galvanizing the auxiliary muscles of respiration, the intercostal muscles, and the phrenic nerve, favor the action of the contractile agents of thoracic and diaphragmatic breathing. But the power of the physician does not go beyond this, and little trust is to be placed on the passing of probangs down the oesophagus, and on the administration of strychnine. Lastly, does the nature of the disease point to a special method of treat- ment? Nothing has been or could be tried on that ground, since those who studied the complaint having only the interpretation of the symptoms to guide them, could only conclude in the existence of a paralysis of unde- termined causation. An injury or the rheumatic diathesis could not be invoked as the cause.; nor could any poison in the blood account for the phenomena observed. So that the symptom paralysis could alone be com- bated. Let me add that the seat of the first manifestations of the disease, and the absence of all cerebral symptom, did not admit of the supposition that the morbid cause was seated in the brain. The pain in the occipital and cervical region, as well as the sensation of pharyngeal constriction, could only suggest the idea of an inflammatory lesion of the bulb and the upper portion of the cord, in the same way as the functional disorders led one to believe that the hypoglossal, the spinal accessory, and the spinal nerves were perhaps diseased at their roots or in some point of their course. But the occipital and cervical pain was not present in all the cases. And even if a lesion of the nervous system could have been almost affirmed, the hy- pothesis of an anatomical lesion could have been expresssed with some reservation only. Dissection alone could shed light on this twofold question of morbid nature and etiology. The post-mortem appearances found in the patient No. 19, St. Agnes Ward, pointed to extensive lesions, which, together with those which we had already found in the patient No. 23, in St. Agnes Ward, and the distinct statements made by Dr. Dumenil, constitute together an amount of information of considerable importance. ON GLOSSO-LARYNGEAL PARALYSIS. 925 From all these facts it follows that, in glosso-laryngeal paralysis, anatomi- cal lesions may be met with characterized by the atrophy of the roots of motor nerves, namely, the hypoglossal, spinal accessory, and spinal nerves. This atrophy, which is thoroughly identical with that described by Profes- sor Cruveilhier and other observers, in cases of progressive muscular atro- phy, seems to be the result of a congestion of ancient date, causing the gradual disappearance of the nerve-tube, and hypergenesis of the connective tissue and neurilemma of the motor roots. The spinal cord itself partici- pates also in the same congestive process. It now remains to determine whether this hypersemia is of an inflamma- tory nature; and if inflammation be once admitted, the predisposing and exciting causes of this inflammatory process will have to be investigated, and the point determined whether it does not depend on a special diathesis. To try and solve such problems would be opening up a vast field to hypothesis. We are at present in possession of no fact which authorizes us to discuss any of them. I prefer taking only into account the hypersemia, as shown by an exaggerated vascular condition, the deposits of hsematin, and the hyperformation of the connective tissue. We should, therefore, merely seek for remedial measures capable of combating this hypersemia. And even then we can hope to interfere with some degree of success only at the outset of the disease, in the stage of congestion ; for when the ana- tomical alteration has been once produced, no practitioner could ever think of making fresh nerve-tubes and of regenerating a portion of the spinal cord. END OF VOLUME ONE. CATALOG-TJE OF LINDSAY & BLAKISTON'S PUBLICATIONS. MEDICAL, DENTAL, CHEMICAL, PHARMACEUTICAL, AND SCIENTIFIC BOOKS. Having for many years given their whole attention to the publication and sale of Medical Books, and keeping on hand as large an assortment as any other house, they are always prepared to fill orders promptly, whether for single books by mail, or in larger quantities by express, at the lowest prices. Being Special Agents in the United States for Messrs. J. & A. CHURCH- ILL, of London, and importing many of their Medical Publications in quantities, they are able to offer them to the Trade or Profession at low rates. IMPORTATION OF BOOKS. As the result of the resumption of specie payments, their rates per shilling for the importation of books have been much reduced. They have also made arrangements to receive packages more fre- quently by STEAMER and EXPRESS, so as to avoid all unnecessary delay in filling orders entrusted to them. THE SYDENHAM SOCIETY'S PUBLICATIONS, for which they are Agents in the United States, will hereafter be supplied to subscribers. at Nine Dollars per annum, payable in advance, and forwarded by mail postage paid. BOOKS BY MAIL will be sent postage paid, and carefully wrapped, upon the receipt of the retail price; or by Express C. O. D. at the usual discount. COMPLETE CLASSIFIED LISTS will be furnished upon application. March, 1879. LINDSAY & BLAKISTON, Medical Publishers and Booksellers, 25 South Sixth St., Philadelphia. IMPORTANT NEW ILLUSTRATED WORKS. FOX'S ATLAS OF SKIN DISEASES. COMPLETE in Eighteen Parts, each containing Four Chromo-Lithographic Plates, with Descriptive Text and Notes upon Treatment. By Tilbury Fox, M.D., F.R.C.P., Physician to the Department for Skin Diseases in University College Hospital. Folio Size. Price, $2.00 each, or complete bound in cloth, Price, $30.00. No Atlas of Skin Diseases has been issued in this country for many years, and no com- plete work of the kind is now procurable by the Profession. This one, brought out under the editorial supervision and care of Dr. Tilbury Fox (the most distinguished writer on Cutaneous Medicine now in the English language), is partly based upon the classical work of Willan and Bateman (now entirely out of print), but completely' remodelled, so as to represent fully the Dermatology of the present day. " Preference will be given to this work over Hebra ; not simply, however, because it is a home pro- duction, but by reason of the manner of its execution, the excellent delineation of disease, and the natural coloring of the plates. . . . The letter-press is entirely new. In the accuracy of the latter the subscriber may have the fullest confidence, since it is from the pen of Dr. Tilbury Fox."-British and Foreign Medico- Chirurgical Review. HUTCHINSON'S ILLUSTRATIONS OF CLINICAL SURGERY. Consisting of Plates, Photographs, Woodcuts, Diagrams, etc.,.illustrating Surgical Diseases, Symptoms, and Accidents; also Operations and other Methods of Treatment. With Descriptive Letter-press. By Jonathan Hutchinson, F. R. C. S., Senior Surgeon to the London Hospital, Surgeon to the Moorfields Ophthalmic Hospital, and to the Hospital for Diseases of the Skin, Blackfriars. In Quarterly Fasciculi. Imperial 4to. $2.50 each. Ten Fasciculi bound in one volume, cloth, complete in itself, Price, $25 00. Parts Eleven, Twelve, and Thirteen Now Ready. BENTLEY AND TRIMEN'S MEDICINAL PLANTS. Being Descriptions, with Original Figures, of the Principal Plants employed in Medicine, and an Account of their Properties and Uses. By R. Bentley, F. L. S., Professor of Botany in King's College, London; Professor of Botany and Materia Medica to the Pharmaceutical Society; and H. Trimen, M. B., F. L. S., Department of Botany, British Museum; Lecturer on Botany in St. Mary's Hospital Medical School. To be completed in about Forty-two Monthly Parts. With Colored Illustrations (natural size). Large 8vo. Price, $2.00 each. Thirty-Six Parts Now Ready. *** This work will serve especially as an illustrated Botanical Guide to the British, United States, and Indian Pharmacopoeias; it will also include other species employed, or in common use though not official. Some others which afford food substances, of value chiefly to invalids, have also been added. Each Plate will be accompanied by letter-press comprehending a full description of the plant in plain scientific language, its nomenclature, geographical distribution, etc., as well as an account of its properties and uses, with full references to previous descriptions and figures and to more special treatises. HEATH'S OPERATIVE SURGERY. A Course of Operative Surgery, consisting of a Series of Plates, each plate containing Numerous Figures, Drawn from Nature by the celebrated Anatomical Artist, M. Leveille, of Paris, Engraved on Steel, and Colored by Hand, under his immediate superintendence, with Descriptive Text of Each Operation. By Christopher Heath, F.R.C.S., Surgeon to University College Hospital, and Holme Professor ot Clinical Surgery in University College, London. Complete in Five Quarto Parts, ■each containing Four Large Plates, and Numerous Figures. Price per Part, $2.50, or bound in one volume, cloth, $14.00. The author has embodied in this work the experience gained by him during twenty years of Surgical Teaching. It comprises all the operations that are required in Ordinary Surgical Practice. He has selected for illustration and description those methods which appear to give the best results in practice, referring to the errors likely to occur and the best methods of avoiding them. . GODLEE'S ATLAS OF HUMAN ANATOMY. An Atlas of Human Anatomy, illustrating most of the ordinary Dissections and many not usually practised by the Student. Accompanied by References and an Explanatory Text. By Rickman John Godlf.e, M.S , F.R.C.S., Fellow of University College; Assistant-Surgeon to University College Hospital, and Senior Demonstrator of Anat- omy in University College. To be completed in Twelve or Thirteen Bi-Monthly Parts, Large Folio Size. Containing Four Plates, Two Figures to each Plate, Colored, and Twenty-four Octavo Pages of Letter-press, forming, when complete, a large Folio Volume of Plates, with References, and an Octavo Volume of Letter-press. Parts I. to VII. Now Ready. Price of each Part, $2.50. SCHULTZE'S LECTURE DIAGRAMS. Lecture Diagrams fjr Instruction in Pregnancy and Midwifery. Twenty Plates of the largest Imperial size, printed in colors. Drawn and Edited with Explanatory Notes, and a 410 volume of letter-press. By Dr. B. S. Schultze, Professor of Mid- wifery at the University of Jena. Prices, in sheets, $15.00. Handsomely mounted on rollers for hanging up. Price * $30.00 BRAUNE'S ATLAS OF TOPOGRAPHICAL ANATOMY. Containing Thirty-Four Full Page Photo-Lithographic Plates, after Plane Sections of Frozen Bodies, and Forty-Six large Wood Engravings. The Photo-Lithographic Plates have Marginal References, and each Plate is accompanied with Full Explanatory Text. By Wilhelm Braune, Professor of Anatomy in the University of Leipsic. Trans- lated by Edward Bellamy, F.R.C.S., Senior Assistant-Surgeon to, and Lecturer on Anatomy and Teacher of Operative Surgery at, the Charing Cross Hospital. Forming a large Imperial Octavo volume. Price, bound in cloth, $12.00 ; half morocco, gilt head, $14.00. SAVAGE'S FEMALE PELVIC ORGANS. The Surgery, Surgical Pathology, and Surgical Anatomy of the Female Pelvic Organs. In a Series of Elegantly-Colored Plates and Diagrams taken from Nature; with Com- mentaries, Notes, and Cases. By Henry Savage, M.D., one of the Consulting Med- ical Officers of the Samaritan Hospital for Women. Third Edition, revised and greatly extended. With an additional Plate, Thirty-Six Engravings, and Special Illus- trations of the Operations on Vesico-vaginal Fistula, Ovariotomy, and Perineal Opera- tions. A large 4to volume. Price, $12.00. ROBERTI FRORIEPI ATLAS ANATOMICUS. Atlas Anatomicus Partium Corporis Humani Per Strata Dispositarum Imagines. In Tab- udus XXX. Ab Augusto Andorffo Delineatas Ferroque Incisas, Exhibens. Editio Sexta, non Mutata. The Thirty Plates contain in all Seventy-six Figures, with Very Full References to all the Muscles, Arteries, Ligaments, etc. Making one of the Finest Anatomical Works ever Published. Printed on Heavy Paper. 1 Vol., Quarto. Plain Plates, $4.00; Colored. Price $10.00 FERBER'S DIAGRAM OF THE THORAX. A Model Diagram of the Thorax and Upper Part of the Abdomen. By A. Ferber., This is a Colored Lithographic Representation in a Dissected Form, or four leaves- showing the above organs as they are met with in the different stages of an Autopsy or in Dissections, and will prove of service in showing the exact Position of the Large Viscera and Blood-Vessels in Post-Mortem Examinations. It also possesses the great merit of Clearness and Portability. On Heavy Paper. Bound on Canvas and in Wooden Frame. 4to size. Price $2.25 JONES' AURAL ATLAS. An Atlas of Diseases of the Membrana Tympani. With Sixty-three Colored Fig- ures, and appropriate letter-press. Quarto,bound in cloth. Price... $6.oo- THE STUDENT'S GUIDE SERIES: Under this general title the publishers are issuing a New Series of Medi- cal Text-Books, or Hand-Books for Practitioners, Moderate in Size and Price, and comprising a Series of Treatises on the Elementary and Practi- cal Branches of Medicine. Each one complete in itself. Prepared by Men of Established Reputation. Containing a Condensed Summary of the Existing State of the Science adapted to the wants of all classes of Medical Men. Sold Separately. NOW READY. 1. The Student's Guide to the Practice of Midwifery. By D. Lloyd Roberts, M. D., Vice-President of the Obstetrical Society of London, Physician to St. Mary's Hospital, Manchester. With 95 Engravings. Price, $2.00 2. The Student's Guide to Human Osteology. By William War- wick Wagstaffe, F. R. C. S., Assistant-Surgeon to, and Lecturer on Anatomy at St. Thomas's Hospital. With 23 full-page Colored Plates, and 66 En- gravings.... 3 00 3. The Student's Guide to Dental Anatomy and Surgery. By Henry E. Sewill, M. R. C. S. Eng., L. D. S., Dental Surgeon to the West London Hospital. With 77 Engravings..... 1.50 4. The Complete Hand-Book of Obstetric Surgery, or, Short Rules of Practice in Every Emergency, from the Simplest to the most Formidable Oper- ations in the Practice of Surgery. By Charles Clay, M. D., Fellow of the London Obstetrical Society, etc. With 101 Illustrations 2.00 5. Surgical Emergencies. A Manual Containing Concise Descriptions of Various Accidents and Emergencies, with Directions for their Immediate Treatment. By W. P. Swain, M. D., Surgeon to the Royal Albert Hospital, etc. With 82 Wood Engravings 2.00 6. A Manual of Minor Surgery and Bandaging, for the Use of House Surgeons, Dressers, and Junior Practitioners. By Christopher Heath, F. R. C. S., Surgeon to University College Hospital, etc. With a Formulae and 86 Illustrations 2.00 7. A Hand-Book on the Diseases and Injuries of the Ear. By W. B. Dalby, F. R. C. S., Aural Surgeon to St. George's Hospital. With 21 Illustrations....- 1.5a 8. The Student's Hand-Book of the Practice of Medicine. With Microscopfc and other Illustrations. By Prof. Charteris, of Glasgow Uni- versity 2.00 9. Practical Gynaicology. A Hand book for Students and Practitioners. With Illustrations. By Heywood Smith, M.D., Physician to the Hospital for Women, etc 1.5c JUST PUBLISHED. Practical Surgery. Including Surgical Dressings, Bandaging Ligations, and Amputations. By J. Ewing Mears, M.D., Demonstrator of Surgery in Jefferson Medical College, etc., etc. 227 Illustrations 2.00 Atthill's Clinical lectures on Diseases Peculiar to Women. Fifth Edition. Revised and Enlarged. With numerous Illustrations 2.25 LINDSAY & BLAKISTON, Publishers, 25 South Sixth Street, Philadelphia. MEDICAL, DENTAL, PHARMACEUTICAL AND SCIENTIFIC BOOKS PUBLISHED BY LINDSAY & BLAKISTON, Philadelphia. ■ ooXXoc AITKEN (william), M. D„ Professor of Pathology in the Army Medical School, iic. THE SCIENCE AND PRACTICE OF MEDICINE. THIRD American, from the Sixth London Edition. Thoroughly Revised, Remodelled, many portions Rewritten, with Additions almost equal to a Third Volume, and numerous additional Illustrations, without any increase in bulk or price. Containing a Colored Map showing the Geographical Distribution of Disease over the Globe, a Lithographic Plate, and nearly 200 Illustrations on Wood. Two volumes, royal octavo, bound in cloth, price, . . $12.00 " " " " leather, . . 14.00 For eighteen months Dr. Aitken has been engaged in again carefully revising this Great Work, and adding to it many valuable additions and improvements, amounting in the ag- gregate almost to a volume of new matter, included in which will be found the adoption and incorporation in the text of the " New Nomenclature of the Royal College of Physicians of London;" to which are added the Definitions and the Foreign Equivalents for their English names; the New Classification of Disease as adopted by the Royal College of Physicians, &c. The American editor, Meredith Clymer, M. D., has also added to it many valuable articles, with special reference to the wants of the American Prac- titioner. The work is now, by almost universal consent, both in England and the United States, acknowledged to be in advance of all other works on The Science and Practice of Medicine. It is a most thorough and complete Text-book for students of medicine, following such a systematic arrangement as will give them a consistent view of the main facts, doctrines, and practice of medicine, in accordance with accurate physiological and pathological principles and the present state of science. For the practitioner it will be found equally acceptable as a work of reference. ALLINGHAM (william), F.R.C.S., Surgeon to St. Mark's Hospital for Fistula, &c. FISTULA, HAEMORRHOIDS, PAINFUL ULCER, STRICT- URE, PROLAPSUS, and other Diseases of the Rectum, their Diagnosis and Treatment. Third Edition, Revised and Enlarged by the Author. Price This book has been well received by the Profession; the first edition sold rap idly; the present one has been revised by the author, and some additions made chiefly as to the mode of treatment. The Medical Press and Circular, speaking of it, says: "No book on this special subject can at all approach Mr. Allingham's in precision, clearness, and practical good sense." The London Lancet: " As a practical guide to the treatment of affections of the lower bowel, this book is worthy of all commendation." The Edinburgh Monthly: "We cordially recommend it as well deserving the careful study of Physicians and Surgeons." 6 ATTHILL (lombe), M. D., Fellow and Examiner in Midwifery, King and Queen's College of Physicians, Dublin. CLINICAL LECTURES ON DISEASES PECULIAR TO WO- MEN. Fifth Edition, Revised and Enlarged, with numerous Illustra- tions. Price $2.00 The value and popularity of this book is proved by the rapid sale of the first edition, which was exhausted in less than a year from the time of its publication. It appears te possess three great merits: First, It treats of the diseases very common to females. Second, ft treats of them in a thoroughly clinical and practical manner. Third, It is concise, orig- inal, and illustrated by numerous cases from the author's own experience. His style is clear and the volume is the result of the author's large and accurate clinical observation recorded in a remarkable, perspicuous, and terse manner, and is conspicuous for the best qualities of a practical guide to the student and practitioner. - British Medical Journal: ADAMS (william), F. R. C. S., Surgeon to the Royal Orthopedic and Great Northern Hospitals. CLUB-FOOT: ITS CAUSES, PATHOLOGY, AND TREAT- MENT. Being the Jacksonian Prize Essay of the Royal College of Surgeons. A New Revised and Enlarged Edition, with 106 Illustrations engraved on Wood, and Six Lithographic Plates. A large Octavo Volume. Price ......... $5.00 ADAMS (robert), M. D., Regius Professor of Surgery in the University of Dublin, &c., &c. RHEUMATIC GOUT, or CHRONIC RHEUMATIC ARTHRI- TIS OF ALL THE JOINTS. The Second Edition. Illustrated by numerous Woodcuts, and a quarto Atlas of Plates. 2 Volumes. Price $7-5o ALTHAUS (julius), M.D., Physician to the Infirmary of Epilepsy and Paralysis. A TREATISE ON MEDICAL ELECTRICITY, Theoretical and Practical, and its Use in the Treatment of Paralysis, Neuralgia, and other Diseases. Third Edition, Enlarged and Revised, with One Hundred and Forty-six Illustrations. In one volume octavo. Price . $6.00 In this work both the scientific and practical aspects of the subject are ably, concisely, and thoroughly' treated. It is much the best work treating of the remedial effects of electricity in the English language. - New York Medical Record. ARNOTT (henry), F.R.C.S. CANCER: its Varieties, their Histology and Diagnosis. With Five Lithographic Plates and Twenty-two Wood Engravings. Price $2.00 AGNEW (d. hayes), M.D., Professor of Surgery In the University of Pennsylvania, THE LACERATIONS OF THE FEMALE PERINEUM, AND VESICO-VAGINAL FISTULA, their History and Treatment, with numerous Illustrations. Octavo. Price . . . . $1.50 Prof. Agnew has been a most indefatigable laborer in this department, and his work stands 'deservedly high in the estimation of the profession. It is well illustrated, and full descrip- tions of the operations and instruments employed are given. - Canada Lancet. 7 ACTON (william), M.R.C.S., etc. THE FUNCTIONS AND DISORDERS OF THE REPRODUC- TIVE ORGANS. In Childhood, Youth, Adult Age, and Advanced Life, considered in their Physiological, Social, and Moral Relations. Fourth American from the Fifth London Edition. Carefully revised by the Author, with additions. . . . . . . . $2.50 Mr. Acton has done good service to society by grappling manfully with sexual vice, and we trust that others, whose position as men of science and teachers enable them to speak with authority, will assist in combating and arresting the evils which it entails. The spirit which pervades his book is one which does credit equally to the head and to the heart of the author. - British and Foreign Medico- Chirurgical Review. AVELING (j. h.), M. D., Physician to Chelsea Hospital for Diseases of Women. THE INFLUENCE OF POSTURE ON WOMEN IN GYNECIC AND OBSTETRIC PRACTICE. Octavo. Cloth. Price . $2.00 ANSTIE (francis e.), M.D., Lecturer on Materia Medica and Therapeutics, etc. STIMULANTS AND NARCOTICS. Their Mutual Relations, with Special Researches on the Action of Alcohol, Ether, and Chloroform on the Vital Organism. Octavo. ..... $3.00 ANDERSON (m'call), M.D., Professor of jClinical Medicine in the University of Glasgow, &c. ECZEMA. The Pathology and Treatment of the various Eczema- tous Affections or Eruptions of the Skin. The Third Revised and En- larged Edition. Octavo. Price . . . . . . $2.50 BUZZARD'S CLINICAL ASPECTS OF SYPHILITIC NER- VOUS AFFECTIONS, nmo. Cloth. Price . . . $1.75 BASHAM'S AIDS TO THE DIAGNOSIS OF DISEASES OF THE KIDNEYS. Sixty Illustrations ..... $1.75 BASHAM ON DROPSY, AND ITS CONNECTION WITH DISEASES OF THE KIDNEYS, HEART, LUNGS, AND LIVER. With Sixteen Plates. Third Edition. Octavo . . . $4.50 BARTH AND ROGERS MANUAL OF AUSCULTATION AND PERCUSSION. From the Sixth French Edition . $1.00 BRADLEY'S MANUAL OF COMPARATIVE ANATOMY AND PHYSIOLOGY. Sixty Illustrations. Third Edition . $2.00 BERNAY'S (albert j.), Ph. D. Professor of Chemistry at St. Thomas's Hospital. NOTES FOR STUDENTS IN CHEMISTRY. Compiled from Fowne's and other Manuals. The Sixth Edition. Cloth . $1.25 BY SAME AUTHOR. THE STUDENT'S GUIDE TO MEDICAL CHEMISTRY. With Illustrations. Preparing. 8 BEALE (lionel s.), M.D. DISEASE GERMS: AND ON THE TREATMENT OF DIS- EASES CAUSED BY THEM. Part l-supposed nature of disease germs. Part II. -REAL NATURE OF DISEASE GERMS. Part III. -THE DESTRUCTION OF DISEASE GERMS. Second Edition, much enlarged, with Twenty-eight full-page Plates, containing 117 Illustrations, many of them colored. Demy Octavo. Price ........... $4-oo This new edition, besides including the contents revised and enlarged of the two former editions published by Dr. Beale on Disease Germs, has an entirely new part added on " The Destruction of Disease Germs." SAME AUTHOR. BIOPLASM. A Contribution to the Physiology of Life, or an Intro- duction to the Study of Physiology and Medicine, for Students. With Numerous Illustrations. Price ...... $2.25 This volume is intended as a Text-Book for Students of Physiology, explaining the nature of some of the most important changes which are characteristic of and peculiar to living beings. PROTOPLASM, OR MATTER AND LIFE. Third Edition, very much Enlarged. Nearly 350 pages. Sixteen Colored Plates. One volume. Price ......... $3.00 Part I. DISSENTIENT. Part II. DEMONSTRATIVE. Part III. SUGGESTIVE. HOW TO WORK WITH THE MICROSCOPE. Fourth Edition, containing 400 Illustrations, many of them colored. Octavo. Price This work is a complete manual of microscopical manipulation, and contains a full descrip- tion of many new processes of investigation, with directions for examining objects under the highest powers, and for taking photographs of microscopic objects. ON KIDNEY DISEASES, URINARY DEPOSITS, AND CAL- CULOUS DISORDERS. Including the Symptoms, Diagnosis, and Treatment of Urinary Diseases. With full Directions for the Chemical and Microscopical Analysis of the Urine in Health and Disease. The Third Edition. Seventy Plates, 415 figures, copied from Nature. Octavo. Price . . . . . . . . . $10.00 THE USE OF THE MICROSCOPE IN PRACTICAL MEDI- CINE. For Students and Practitioners, with full directions for exam- ining the various secretions, &c., in the Microscope. Fourth Edition. 500 Illustrations. Octavo. Much enlarged. Price . . $7.50 BLOXAM (c. l.), Professor of Chemistry in King's College, London. CHEMISTRY, INORGANIC AND ORGANIC. With Experi- ments and a Comparison of Equivalent and Molecular Formulae. With 276 Engravings on Wood. . Third London Edition, revised. Octavo. Price, in cloth, $4.00; leather, . . . . . . $5.00 SAME AUTHOR. LABORATORY TEACHING; OR PROGRESSIVE EXER- CISES IN PRACTICAL CHEMISTRY. Third Edition. With Eighty-nine Engravings. Crown Octavo. Price . . . $2.00 BENNETT (j. henry), M. D. NUTRITION IN HEALTH AND DISEASE. A Contribution to Hygiene and to Clinical Medicine. Third Edition, Revised and Enlarged. Octavo. Cloth. Price $2.50 BY SAME AUTHOR. THE TREATMENT OF PULMONARY CONSUMPTION BY HYGIENE, CLIMATE, AND MEDICINE. With an Appendix on the Sanitaria of the United States, Switzerland, and the Balearic Isl- ands. The Third Edition, much Enlarged. Octavo. Price . $2.50 BUCKNILL (JOHN CHARLES), M.D., & TUKE (daniel h.),M.D. A MANUAL OF PSYCHOLOGICAL MEDICINE: containing the Lunacy Laws, the Nosology, CEtiology, Statistics, Description, Diagno- sis, Pathology (including Morbid Histology), and Treatment of Insanity. Fourth Edition, much enlarged, with Ten Lithographic Plates, and nu- merous other Illustrations. Octavo. Preparing. This edition will contain a number of pages of additional matter, and, in consequence of recent advances in Psychological Medicine, several chapters will be rewritten, bringing the Classification, Pathology, and Treatment of Insanity up to the present time. BROWNE (j. h. balfour), Esq. MEDICAL JURISPRUDENCE OF INSANITY. Second Edition, very much Enlarged. With References to the Scotch and American Decisions, etc., etc. Octavo. Price . . . . . $5.00 BIDDLE (john'b.), M. D., Professor of Materia Medicaand Therapeutics in the Jefferson Medical College, Philadelphia, &o. MATERIA MEDICA, FOR THE USE OF STUDENTS. With Illustrations. Eighth Edition, Revised and Enlarged. Price $4.00 This new and thoroughly revised edition of Professor Biddle's work has incorporated in it all the improvements as adopted by the New United States Pharmacopoeia just issued. It is designed to present the leading facts and principles usually comprised under this head as set forth by the standard authorities, and to fill a vacuum which, seems to exist in the want of an elementary work on the subject. The larger works usually recommended as text-books in our Medical schools are too voluminous for convenient use. This will be found to contain, in a condensed form, all that is most valuable, and will supply students with a reliable guide to the course of lectures on Materia Medica as delivered at the various Medical schools in the United States. BALFOUR~7g7w.), m. d., Physician to the Royal Infirmary, Edinburgh) Lecturer on Clinical Medicine, &c. CLINICAL LECTURES ON DISEASES OF THE HEART AND AORTA. With Illustrations. Octavo. Price . . . $4.00 BYFORD (w~h\ A.M., M.D., Professor of Obstetrics and Diseases of Women and Children in the Chicago Medical College, &c, PRACTICE OF MEDICINE AND SURGERY. Applied to the Diseases and Accidents incident to Women. Second Edition, Revised and Enlarged. Octavo. Price SAME AUTHOR. ON THE CHRONIC INFLAMMATION AND DISPLACEMENT OF THE UNIMPREGNATED UTERUS. A New, Enlarged, and Thoroughly Revised Edition, with Numerous Illustrations. 8vo. $2.50 Dr. Byford writes the exact present state of medical knowledge on the subjects presented; and does this so clearly, so concisely, so truthfully, and so completely, that his book on the uterus will always meet the approval of the profession, and be everywhere regarded as a popular standard work. - Buffalo Medical and Surgical Journal. 9 10 BLACK (d. Campbell), M. D., L. R. C. S. Edinburgh, Member of the General Council of the University of Glasgow, &.C., &c. THE FUNCTIONAL DISEASES OF THE RENAL, URINARY, and Reproductive Organs, with a General View of Urinary Pathology. Price $2.Oo The style of the author is clear, easy, and agreeable, . . . his work is a valuable contri- bution to medical science, and being penned in that disposition of unprejudiced philosophical inquiry which should always guide a true physician, admirably embodies the spirit of its opening quotation from Professor Huxley. - Philada. Med. Times. * I BY SAME AUTHOR. LECTURES ON BRIGHT'S DISEASE OF THE KIDNEYS. Delivered at the Royal Infirmary of Glasgow. With 20 Illustrations, engraved on Wood. One volume, octavo, in Cloth. Price . $1.50 BENTLEY and TRIMEN'S MEDICINAL PLANTS. A New Illustrated Work, now Publish- ing in Monthly Parts. Thirty-seven Parts now ready. Eight Colored Plates in each Part. Price, each, . . . . . . $2.00 This work includes full botanical descriptions, and an account of the properties and uses of the principal plants employed in medicine, especial attention being paid to those which are officinal in the British and United States Pharmacopoeias. The plants which supply food and substances required by the sick and convalescent will be also included. Each spe- cies will be illustrated by a colored plate drawn from nature. BEASLEY (henry). THE BOOK OF PRESCRIPTIONS. Containing over 3000 Prescriptions, collected from the Practice of the most Eminent Physi- cians and Surgeons - English, French, and American ; comprising also a Compendious History of the Materia Medica, Lists of the Doses of all Officinal and Established Preparations, and an Index of Diseases and their Remedies. Fifth Edition, Revised and Enlarged. Price $2.25 BY SAME AUTHOR. THE POCKET FORMULARY: A Synopsis of the British and Foreign Pharmacopoeias. Tenth Revised Edition. Price . $2.25 THE DRUGGIST'S GENERAL RECEIPT BOOK and VETERI- NARY FORMULARY. Eighth Edition. Just Ready. Price, $2.25 BIRCH (s. b.), M. D., Member of the Royal College of Physicians &c, CONSTIPATED BOWELS; the Various Causes and the Different Means of Cure. Third Edition. Price . . . $1.00 BRAUNE-BELLAMY. AN ATLAS OF TOPOGRAPHICAL ANATOMY. After Plane Sections of Frozen Bodies, containing Thirty-four Full-page Photo- graphic Plates and numerous other Illustrations on Wood. By Wilhelm Braune, Professor of Anatomy in the University of Leipzig. Trans- lated and Edited by Edward Bellamy, F. R. C. S., Senior Assistant Sur- geon to, and Lecturer on Anatomy and Teacher of Operative Surgery at, the Charing Cross Hospital, London. A large quarto volume. Price in cloth, $12.00 ; half morocco, $14.00 11 COHEN (i. solis), M.D. Lecturer on Laryngoscopy and Diseases of the Throat and Chest in Jefferson Medical College, ON INHALATION. ITS THERAPEUTICS AND PRACTICE Including a Description of the Apparatus employed, &c. With Cases and Illustrations. A New Enlarged Edition. Price . . $2.50 SAME AUTHOR. CROUP. In its Relations to Tracheotomy. Price . . $1.00 CARSON (joseph), M.D., Professor of Materia Medica and Pharmacy in the University, A HISTORY OF THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF PENNSYLVANIA, from its Foundation in 1765: with Sketches of Deceased Professors, &c. .... $2.00 CHARTERIS (mathew), M. D., Member of Hospital Staff and Professor in University of Glasgow. STUDENTS' HAND-BOOK OF THE PRACTICE OF MEDI- CINE. With Microscopic and other Illustrations. Price . $2.00 This book forms one volume of the Students' Guide Series, or Text-Books, now in course of publication. CARPENTER (w. b.), M.D., F.R.S. THE MICROSCOPE AND ITS REVELATIONS. The Fifth London Edition, Revised and Enlarged, with more than 500 Illustra- tions . . . . $5.00 CORR (l. h.), M.D. OBSTETRIC CATECHISM, or Obstetrics reduced to Questions and Answers. With Numerous Illustrations. Price . . $2.00 CHAVASSE (p. henry), F.R.C.S., Author of Advice to a Wife, Advice to a Mother, &c, APHORISMS ON THE MENTAL CULTURE AND TRAIN- ING OF A CHILD, and on various other subjects relating to Health and Happiness. Addressed to Parents. Price . . $1.00 Dr. Chavasse's works have been very favorably received and had a large circulation, the value of his advice to WIVES and MOTHERS having thus been very generally recognized. This book is a sequel or companion to them, and it will be found both valuable and important to all who have the care of families, and who want to bring up their children to become useful men and women. It is full of fresh thoughts and graceful illustrations. CLARKE (w.fairlie), M.D., Assistant Surgeon to Charing Cross Hospital. CLARKE'S TREATISE ON DISEASES OF THE TONGUE. With Lithographic and Wood-cut Illustrations. Octavo. Price $4.50 It contains The Anatomy and Physiology of the Tongue, Importance of its Minute Exam- ination, Its Congenital Defects, Atrophy, Hypertrophy, Parasitic Diseases, Inflammation, Syphilis and its effects, Various Tumors to which it is subject, Accidents, Injuries, &c., &c. COOPER (s.). A DICTIONARY OF PRACTICAL SURGERY AND ENCY- CLOPAEDIA OF SURGICAL SCIENCE. New Edition, brought down to the present time. By Samuel A. Lane, F.R.C.S., assisted by other eminent Surgeons. In two vols., of over 1000 pages each. $12.00 12 CLAY (charles), M. D. Fellow of the London Obstetrical Society, &c. THE COMPLETE HAND-BOOK OF OBSTPSTRIC SURGERY, or, Short Rules of Practice in Every Emergency, from the Simplest to the most Formidable Operations in the Practice of Surgery, hirst American from the Third London Edition. With numerous Illustra- tions. In one volume. $2.00 CHAMBERS (thomas k.), M. D„ LECTURES, CHIEFLY CLINICAL. Illustrative of a Restorative System of Medicine. CORMACK (sir john rose), K. B., F. R. S. E., M. D. Edinburgh and Paris, Fellow Royal College of Physicians, Physician to the Hertford British Hospital, Paris, &c. CLINICAL STUDIES, Illustrated by Cases observed in Hospital and Private Practice. With Illustrative Plates. 2 Volumes. Octavo. $5.00 COBBOLD (t. spencer), M.D., F.R.S. WORMS: a Series of Lectures delivered at the Middlesex Hospital on Practical Helminthology. Post Octavo. . . . . $1.75 CLEAVELAND (c. h.), M.D., Member of the American Medical Association, &c. A PRONOUNCING MEDICAL LEXICON. Containing the Cor- rect Pronunciation and Definition of Terms used in Medicine and the Collateral Sciences. Improved Edition, Cloth, $1.00; Tucks, $1.25 This work is not only a Lexicon of all the words in common use in Medicine, but it is also a Pronouncing Dictionary, a feature of great value to Medical Students. To the Dis- penser it will prove an excellent aid, and also to the Pharmaceutical Student. It has received strong commendation both from the Medical Press and from the profession. COLES (OAKLEY), D.D.S. Dental Surgeon to the Hospital for Diseases of the Throat, &c. A MANUAL OF DENTAL MECHANICS. Containing much information of a Practical Nature for Practitioners and Students. INCLUDING The Preparation of the Mouth for Artificial Teeth, on Taking Impressions, Various Modes of Applying Heat in the Laboratory, Casting in Plaster of Paris and Metal, Precious Metals used in Dentistry, Making Gold Plates, Various Forms of Porcelain used in Mechanical Dentistry, Pivot Teeth, Choosing and Adjusting Mineral Teeth, the Vulcanite Base, the Celluloid Base, Treatment of Deformities of the Mouth, Receipts for Making Gold Plate and Solder, etc., etc. With 140 Illustrations. Price ...... $2.00 SAME AUTHOR. ON DEFORMITIES OF THE MOUTH, CONGENITAL AND ACQUIRED, with their Mechanical Treatment. Second Edition, Re- vised and Enlarged. With Illustrations. Price, DOMVILLE (edward j.), M. D. A MANUAL FOR HOSPITAL NURSES and Others engaged in Attending the Sick. 121110. Price $1.00 13 CLARK (f. le gros), F. R. S., Senior Surgeon to St. Thomas's Hospital. OUTLINES OF SURGERY AND SURGICAL PATHOLOGY, including the Diagnosis and Treatment of Obscure and Urgent Cases, and the Surgical Anatomy of some Important Structures and Regions. Assisted by W. W. Wagstaffe, F. R. C. S., Resident Assistant-Surgeon of, and Joint Lecturer on Anatomy at, St. Thomas's Hospital. Second Edition, Revised and Enlarged. Price . . . . $2.00 COTTLE (e. wyndham), M. A., F R. C. S., &c. THE HAIR IN HEALTH AND DISEASE. Partly from Notes by the late George Nayler, F. R. C. S., Surgeon to the Hospital for Diseases of the Skin, &c. i8mo. Cloth. Price . . $0.75 CURLING (t. b.), F.R.S., Consulting Surgeon to the London Hospital, &c. A PRACTICAL TREATISE ON THE DISEASES OF THE TESTIS AND OF THE SPERMATIC CORD AND SCROTUM. Fourth Revised and Enlarged Edition. Octavo. Price. . $5.50 BY SAME AUTHOR. OBSERVATIONS ON DISEASES OF THE RECTUM. With Illustrations. Fourth Edition, Revised and Enlarged. Octavo. Cloth. Price ........... $2.75 CAZEAUX (p.), M. D., Adjunct Professor of the Faculty of Medicine, Paris, etc. A THEORETICAL AND PRACTICAL TREATISE ON MIDWIFERY, including the Diseases of Pregnancy and Parturition. Translated from the Seventh French Edition, Revised, Greatly Enlarged, and Improved, by S. Tarnier, Clinical Chief of the Lying-In Hospital, Paris, etc., with numerous Lithographic and other Illustrations. Price, in Cloth, $6.00; in Leather ........ $7-oo M. Cazeaux's Great Work on Obstetrics has become classical in its character, and almost an Encyclopaedia in its fulness. Written expressly for the use of students of medicine, its teachings are plain and explicit, presenting a condensed summary of the leading principles established by the masters of the obstetric art, and such clear, practical directions for the management of the pregnant, parturient, and puerperal states, as have been sanctioned by the most authoritative practitioners, and confirmed by the author's own experience. DOBELL (horace), M. D., Senior Physician to the Hospital. WINTER COUGH (CATARRH, BRONCHITIS, EMPHYSEMA, ASTHMA). Lectures Delivered at the Royal Hospital for Diseases of the Chest. The Third Enlarged Edition, with Colored Plates. Octavo. Price $3-5° BY SAME AUTHOR. ON LOSS OF WEIGHT, BLOOD-SPITTING, AND LUNG DISEASE. With a Colored Frontispiece of the Lung, a Tabular Map, &c., &c. Octavo. Cloth. Price ..... $3.25 14 DIXON (james), F. R. C. S. Surgeon to the Royal London Ophthalmic Hospital, &c. A GUIDE TO THE PRACTICAL STUDY OF DISEASES OF THE EYE, with an Outline of their Medical and Operative Treatment, with Test Types and Illustrations. Third Edition, thoroughly Revised, and a great portion Rewritten. Price ..... $2.00 Mr. Dixon's book is essentially a practical one, written by an observant author, who brings to his special subject a sound knowledge of general Medicine and Surgery.-Dublin Quarterly. DILLNBERGER (dr. emil). A HANDY-BOOK OF THE TREATMENT OF WOMEN AND CHILDREN'S DISEASES, according to the Vienna Medical School. Part I. The Diseases of Women. Part II. The Diseases of Children. Translated from the Second German Edition, by P. Nicol, M. D. Price . . . . . . . . . . Many practitioners will be glad to possess this little manual, which gives a large mass of practical hints on the treatment of diseases which probably make up the larger half of every-day practice. The translation is well made, and explanations of reference to German medicinal preparations are given with proper fulness. - The Practitioner. DUNGLISON (richard j.), M. D. THE PRACTITIONER'S REFERENCE BOOK. Containing Therapeutic and Practical Hints, Dietetic Rules and Precepts, and other General Information Useful to the Physician, Pharmacist, and Student. Octavo. Cloth. Price . . ' . . . $3.50 DUCHENNE (dr. g. b.). LOCALIZED ELECTRIZATION AND ITS APPLICATION TO PATHOLOGY AND THERAPEUTICS. Translated by Her- bert Tibbits, M.D. With Ninety-two Illustrations. Price . $3.00 Duchenne's great work is not only a well-nigh exhaustive treatise on the medical uses of Electricity, but it is also an elaborate exposition of the different diseases in which Electric- ity has proved to be of value as a therapeutic and diagnostic agent. Part II., illustrated by chromo-lithographs and numerous wood-cuts, is preparing. DURKEE (silas), M.D., Fellow of the Massachusetts Medical Society, &c. GONORRHCEA AND SYPHILIS. The Sixth Edition, Revised and Enlarged, with Portraits and Eight Colored Illustrations. Octavo. Price ........... $3.50 Dr. Durkee's work impresses the reader in favor of the author by its general tone, the thorough honesty everywhere evinced, the skill with which the book is arranged, the man- ner in which the facts are cited, the clever way in which the author's experience is brought in, the lucidity of the reasoning, and the care with which the therapeutics of venereal com plaints are treated.-Lancet. DRUITT (ROBERT), F.R.C.S. THE SURGEON'S VADE-MECUM. A Manual of Modern Sur- gery. The Eleventh Revised and Enlarged Edition, with 369 Idus- trations. Price . . . . . . . . $5.00 15 DALBY (w. b.), F. R. C. S., Aural Surgeon to St. George's Hospital. LECTURES ON THE DISEASES AND INJURIES OF THE EAR. Delivered at St. George's Hospital. With Illustrations. Price . . . . . . . . . . . $1.50 We cordially recommend this admirable volume by Mr. Dalby as a trustworthy guide in the treatment of the affections of the ear. The book is moderate in price, beautifully illus- trated by wood-cuts, and got up in the best style. - Glasgow Medical Journal. DAY (william henry), M. D., Physician to the Samaritan Hospital for Women and Children, &c. HEADACHES, THEIR NATURE, CAUSES, AND TREAT- MENT. Second Edition. 121110. Cloth. Price . . $2.00 DUNGLISON (robley), M. D„ Late Professor of Institutes of Medicine, &c., in the Jefferson Medical College. A HISTORY OF MEDICINE, from the Earliest Ages to the Com- mencement of the Nineteenth Century. Edited by his son, Richard J. Dunglison, M. D $2.50 ELLIS (edward), M. D., Physician to the Victoria Hospital for Sick Children, &c. A PRACTICAL MANUAL OF THE DISEASES OF CHIL- DREN, with a Formulary. Third Enlarged Edition, Revised and Improved. One'volume. ....... $2.00 The author, in issuing this new edition of his book, says: "I have very carefully revised each chapter, adding several new sections, and making considerable additions where the subjects seemed to require fuller treatment, without, however, sacrificing conciseness 01 unduly increasing the bulk of the volume." ELAM (charles), M. D., F.R.C.P. ON CEREBRIA AND OTHER DISEASES OF THE BRAIN. Octavo. .......... $2.50 FOTHERGILL (j. milner), M. D. THE HEART AND ITS DISEASES, AND THEIR TREAT- MENT. With Illustrations. Octavo. Second Edition Preparing. FOX (CORNELIUS B.), M. D. SANITARY EXAMINATIONS of Water, Air, and Food. 94 En- gravings. 8vo. Price ....... $4.00 FOX (tilbury), M. D., F. R. C. P. Physician to the Department for Skin Diseases in University College Hospital. ATLAS OF SKIN DISEASES. Consisting of a Series of Colored Illustrations, in Monthly Parts, together with Descriptive Text and Notes upon Treatment; each Part containing Four Plates, reproduced by Chromo-Lithography from the work of Willan & Bateman, or taken from Original Sources. Now Complete in 18 Parts. Price, per Part, $2.00 ; or in one large Folio volume, bound in cloth. Price . . $30.00 16 FENNER (c. s.), M. D., &c. VISION: ITS OPTICAL DEFECTS, and the Adaptation of Spec- taeles; embracing Physical Optics, Physiological Optics, Errors of Re- fraction and Defects of Accommodation, or Optical Defects of the Eye. With 74 Illustrations. Selections from the Test Types of Jaeger and Snellen, etc. Octavo. Price ...... $3.50 FOSTER (balthazar), M. D., Professor of Medicine in Queen's-College. LECTURES AND ESSAYS ON CLINICAL MEDICINE. Re- vised and Enlarged by the Author. With Engravings. Octavo. Price $3.00 FRANKLAND (e.), M. D., F. R. S., &c. HOW TO TEACH CHEMISTRY, being the substance of Six Lectures to Science Teachers. Reported, with the Author's sanction, by G. George Chaloner, F. C. S., &c. With Illustrations . $1.25 FENWICK (samuel), M.D., F R.C.P. THE MORBID STATES OF THE STOMACH AND DUO- DENUM, AND THEIR RELATIONS TO THE DISEASES OF OTHER ORGANS. With Ten Plates. .... $4.25 FLINT (austin), M. D., Professor of the Principles and Practice of Medicine, &c., Bellevue Hospital College, New York. CLINICAL REPORTS ON CONTINUED FEVER. Based on an Analysis of One Hundred and Sixty-four Cases, with Remarks on the Management of Continued Fever; the Identity of Typhus and Typhoid Fever; Diagnosis, &c., &c. Octavo. Price . . $2.00 GANT (FREDERICK J.), F. R. C. S., Assisted by Drs. Morrell, Mackenzie, Barnes, Erasmus Wilson, and other Specialists. THE SCIENCE AND PRACTICE OF SURGERY. Second Edition. 1700 Pages. 1000 Illustrations. 2 Vols. Trice, cloth, $11.00 ; sheep . . . . . . . . . . . $13.00 DISEASES OF THE BLADDER, PROSTATE GLAND, AND URETHRA, including a Practical View of Urinary Diseases, Deposits, and Calculi. Fourth Edition, Revised and Enlarged. With New Il- lustrations. Now Ready. Price ...... $3-5° GODLEE (r. j.), M. D., Assistant-Surgeon University College Hospital. AN ATLAS OF HUMAN ANATOMY. Illustrating the Anatomy of the Human Body, in a Series of Dissections. Accompanied by References and an Explanatory Text. To be completed in Twelve or Thirteen Bi-monthly Parts, Folio Size, each Part containing Four large Colored Plates, or Eight Figures. Seven Parts Now Ready. Price per Part ..... ...... $2.50 17 GROSS (SAMUEL D.), M. D., Professor of Surgery in the Jefferson Medical College, Philadelphia, etc. AMERICAN MEDICAL BIOGRAPHY OF THE NINETEENTH CENTURY. With a Portrait of Benjamin Rush, M.D. Octavo. $3.50 GREEN HOW (e. headlam), M. D., Fellow of the Royal College of Physicians, etc. ON CHRONIC BRONCHITIS, Especially as Connected with Gout, Emphysema, and Diseases of the Heart. Price . . . $1.50 BY SAME AUTHOR. ADDISON'S DISEASE. Being the Cronian Lectures for 1875. Delivered before the Royal College of Physicians. Revised, and Illus- trated by numerous Cases and 5 full-page Colored Engravings. One volume, octavo. Price $3.00 HARLEY (george), M. D., F. R. C. P, Physician to University College Hospital. THE URINE AND ITS DERANGEMENTS: With the Applica- tion of Physiological Chemistry to the Diagnosis and Treatment of Constitutional as well as Local Diseases. New Revised and Enlarged Edition preparing. With Engravings. We have here a valuable addition to the library of the practising physician; not only for the information which it contains, but also for the suggestive way in which many of the subjects are treated, as well as for the fact that it contains the ideas of one who thoroughly believes in the future capabilities of Therapeutics based bn Physiological facts, and in the important service to be rendered by Chemistry to Physiological investigation. American Journal of the Medical /Science. HEATH (Christopher), F. R. C. S., Surgeon to University College Hospital and Holme Professor of Clinical Surgery in University College. OPERATIVE: SURGERY. Elegantly Illustrated by 20 Large Col- ored Plates, Imperial Quarto Size, each Plate containing several Fig- ures, drawn from Nature by M. Leveille, of Paris, and Colored by hand under his direction. Complete in Five Quarterly Parts. Price, per Part, $2.50; or in one volume, handsomely bound in cloth. Price $14.00 HEWITT (graiiy), M. D., Physician to the British Lying-In Hospital, and Lecturer on Diseases of Women and Children, &c. THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF WOMEN, including the Diagnosis of Pregnancy. Founded on a Course of Lectures delivered at St. Mary's Hospital Medical School. The Third Edition, Revised and Enlarged, with new Illustrations. Octavo. Price in Cloth . . . $4.00 " Leather . . . 5.00 This new edition of Dr. Hewitt's book has been so much modified, that it may be considered substantially a new book; very much of the matter has been entirely rewritten, and the whole work has been rearranged in such a manner as to present a most decided improvement over previous editions. Dr. Hewitt is the leading clinical teacher on Diseases of Women in London, and the characteristic attention paid to Diagnosis by him has given his work great popularity there. It may unquestionably be considered the most valuable guide to correct Diagnosis to be found in the English language. 2 18 HILLIER (thomas), M.D., Physician to the Hospital for Sick Children, &c, A CLINICAL TR EATISE ON THE DISEASES OF CHILDREN. Octavo. Price ......... $2.00 We have said enough to indicate and illustrate the excellence of Dr. Hillier's volume. It is eminently the kind of book needed by all medical men who wish to cultivate clinical accuracy and sound practice. - London Lancet. HOLDEN (luther), F.R.C.S. HUMAN OSTEOLOGY, comprising a Description of the Bones with Delineations of the Attachments of the Muscles, &c. With numerous Illustrations. Fifth Edition, carefully Revised. Price, $5.50 HOLDEN'S MANUAL OF DISSECTIONS OF THE HUMAN BODY. Fourth London Edition. With Illustrations. Price LANDMARKS, MEDICAL AND SURGICAL. Second Edition, Revised and Enlarged. Price . . . . . . $1.00 HARRIS (chapin A.), M. D., D. D. S. Late President of and Professor of the Principles and Practice of Dental Surgery in the Baltimore College, &.c. THE PRINCIPLES AND PRACTICE OF DENTISTRY. Tenth Revised Edition. In great part rewritten, rearranged, and with many new and important Illustrations. Including-1. Dental Anatomy and Physiology. 2. Dental Pathology and Therapeutics. 3. Dental Sur- gery. 4. Dental Mechanics. Edited by P. H. Austen, M.D., Pro- fessor of Dental Science and Mechanism in the Baltimore College of Dental Surgery. With nearly 400 Illustrations, including many new ones made especially for this edition. Royal octavo. Price, in cloth, $6.50; in leather ........ $7.50 This new edition of Dr. Harris's work has been thoroughly revised in all its parts-more so than any previous edition. So great have been the advances in many branches of dentistry, that it was found necessary to rewrite the articles or subjects, and this has been done in the most efficient manner by Professor Austen, for many years an associate and friend of Dr. Harris, assisted by Professor Gorgas and Thomas S. Latimer, M. D. The publishers feel assured that it will now be found the most complete text-book for the student and guide for the practitioner in the English language. SAME AUTHOR. A DICTIONARY OF MEDICAL TERMINOLOGY, DENTAL SURGERY, AND THE COLLATERAL SCIENCES. Fourth Edition, Carefully Revised and Enlarged, by Ferdinand J. S. Gorgas, M. D., D.D.S., Professor of Dental Surgery in the Baltimore College, &c., &c. Royal octavo. Price, in cloth, $6.50; in leather . . $7-5° The many-advances in Dental Science rendered it necessary that this edition should be thoroughly revised, which has been done in the most satisfactory manner by Professor Gorgas, Dr. Harris's successor in the Baltimore Dental College, he having added nearly three thou- sand new words, besides making many additions and corrections. The doses of the more prominent medicinal agents have also been added, and in every way the book has been greatly improved, and its value enhanced as a work of'reference. . HABERSHON (s. o.), M. D„ F. R. C. P„ Senior Physician, Guy's Hospital. ON DISEASES OF THE ABDOMEN, STOMACH, and Other Parts of the Alimentary Canal. Third Edition. 8vo. Price . $5.00 19 HARDWICH AND DAWSON. HARDWICK'S MANUAL OF PHOTOGRAPHIC CHEMISTRY. With Engravings. Eighth Edition. Edited and Rearranged by G. Dawson, Lecturer on Photography, &c., &c. i2mo. . . $2.00 The object of the Editor has been to give practical instruction in this fascinating art, and to lead the novice from first principles to the higher branches, impressing him with the value of care and exactness in every operation. HEADLAND (f. w.), M. D„ Fellow of the Royal College of Physicians, &c., &c. ON THE ACTION OF MEDICINES IN THE SYSTEM. Sixth American from the Fourth London Edition. Revised and Enlarged. Octavo. Price $3.00 Dr. Headland's work gives the only scientific and satisfactory view of the action of medi- cine; and this not in the way of idle speculation, but by demonstration and experiments, and inferences almost as indisputable as demonstrations. It is truly a great scientific work in a small compass, and deserves to be the hand-book of every lover of the Profession. It has received the approbation of the Medical Press, both in this country and in Europe, and is pronounced by them to be the most original and practically useful work that has been issued for many years. HOFF (o.), M. D. ON HzEMATURIA as a Symptom of Diseases of the Genito-Uri- nary Organs. Illustrated. i2mo. Cloth. .... $0.75 HEATH (Christopher), F.R.C.S., Surgeon to University College Hospital, &c. INJURIES AND DISEASES OF THE JAWS. The Jacksonian Prize Essay of the Royal College of Surgeons of England, 1867. Sec- ond Edition, Revised, with over 150 Illustrations. Octavo. Price, $4-25 SAME AUTHOR. A MANUAL OF MINOR SURGERY AND BANDAGING, for the Use of House Surgeons, Dressers, and Junior Practitioners. With a Formulae and Numerous Illustrations. i6mo. Price . $2.00 HAYDEN (thomas), M. D., Fellow of the King and Queen's College of Physicians, &c., &c. THE DISEASES OF THE HEART AND AORTA. With 81 Illustrations. In two volumes, Octavo, of over 1200 pages. Price, $6.00 • HUFELAND (c. w.), M.D. THE ART OF PROLONGING LIFE. Edited by Erasmus Wil- son, M. D., F. R.S., &c. i2mo. Cloth. .... $1.00 HAY (thomas), M. D., HISTORY OF A CASE OF RECURRING SARCOMATOUS TUMOUR OF THE ORBIT IN A CHILD. With Three Full Page Illustrations, representing the Tumour in its Various Stages. Price, $0.50 20 HEWSON (addinell,) M. D. Attending Surgeon Pennsylvania Hospital, &c. EARTH AS A TOPICAL APPLICATION IN SURGERY. Being a full Exposition of its use in all the Cases requiring Topical Applications admitted in the Surgical Wards of the Pennsylvania Hospi- tal during a period of Six Months. With Illustrations. Price $2.50 HUTCHINSON (Jonathan), F. R. C. S. Senior Surgeon to the London Hospital. ILLUSTRATIONS OF CLINICAL SURGERY. Consisting of Plates, Photographs, Wood-cuts, Diagrams, etc., Illustrating Surgical Diseases, Symptoms and Accidents, also Operations and other Methods of Treatment. With Descriptive Letter-press. 10 Parts Bound, com- plete in itself. Price, $25.00. Parts 11 and 12 now ready. Price, $2.50 'ipp11 Prospectuses furnished upon application. HODGE (hugh l.), M. D. Emeritus Professor in the University of Pennsylvania. HODGE ON FOETICIDE, OR CRIMINAL ABORTION. Fourth Edition. Price, in paper, 30 cents; in cloth, . $0.50 HODGE'S (h. lenox) NOTE-BOOK FOR CASES OF OVARIAN TUMORS. With Diagrams, etc. Price, .... $0.50 HOLDEN (edgar), A. M„ M. D„ Of Newark, New Jersey. CONTAINING THREE HUNDRED ILLUSTRATIONS. THE SPHYGMOGRAPH. Its Physiological and Pathological In- dications. The Essay to which was awarded the Stevens Triennial Prize in the College of Physicians and Surgeons in New York, April, 1873. Illustrated by Three Hundred Engravings on Wood. One vol- ume octavo. Price. . . . . . . . . $2.00 HOOD (p.), M.D. A TREATISE ON GOUT, RHEUMATISM, AND THE ALLIED AFFECTIONS. Crown octavo. $4.25 JONES (h. macnaughton), M. D., M. Ch. A PRACTICAL TREATISE ON AURAL SURGERY. Ulus trated. i2mo. Price . . . . . . . . $1.50 JONES (t. wharton), F.R.S. DEFECTS OF SIGHT AND HEARING. Their Nature, Causes, Prevention, &c. Second Edition. Price . $0.50 JONES, SIEVEKING, and PAYNE. A MANUAL OF PATHOLOGICAL ANATOMY. By C. Hand- field Jones, M. D., F. R. S., Physician to St. Mary's Hospital; and Edward H. Sieveking, M.D., F.R.C.P., Physician to St.Mary's Hos- pital. A New and Enlarged Edition. Edited by J. F. Payne, M.B., F. R. C.P., Assistant Physician and Lecturer on Morbid Anatomy at St. Thomas's Hospital. With Numerous Illustrations. . . $5.50 21 JAMES (prosser), M. D., M. R. C. P., Physician to Throat Hospital. SORE THROAT : Its Nature,Varieties, and Treatment, and its Con- nection with other Diseases. Third Edition. Colored Plates. i2mo. Price $2.00 JONES' AURAL ATLAS. AN ATLAS OF DISEASES OF THE MEMBRANA TYMPANI. Being a Series of Colored Plates, containing 62 Figures. With appro- priate Letter-Press and Explanatory Text by H. McNaughton Jones, M.D., Surgeon to the Cork Ophthalmic and Aural Hospital. 4to. Cloth. Price ......... $6.00 LAWSON (george), F. R.C.S., Surgeon to the Royal London Ophthalmic Hospital. DISEASES AND INJURIES OF THE EYE, THEIR MEDICAL AND SURGICAL TREATMENT. Containing a Formulary, Test Types, and Numerous Illustrations. Price . . . . $2.00 This Manual is admirably clear and eminently practical. The reader feels that he is in the hands of a teacher who has a right to speak with authority, and who, if he may be said to be positive, is so from the fulness of knowledge and experience, and who, while well ac- quainted with the writings and labors of other authorities on the matters he treats of, has himself practically worked out what he teaches. - London Medical Times and Gazette. LEBER & ROTTENSTEIN (drs.). DENTAL CARIES AND ITS CAUSES. An Investigation into the Influence of Fungi in the destruction of the Teeth, translated by Thomas H. Chandler, D.M.D., Professor of Mechanical Dentistry in the Dental School of Harvard University. With Illustrations. Octavo. Price ........... $1.25 This work is now considered the best and most elaborate work on Dental Caries. It is everywhere quoted and relied upon as authority by the profession, who have seen it in the original, and by authors writing on the subject. LEGG (j. wickham), M. D. Member of the Royal College of Physicians, &c. A GUIDE TO THE EXAMINATION OF THE URINE. For the Practitioner and Student. Fourth Edition. i6mo. Cloth. Price, $0.75 Dr. Legg's little manual has met with remarkable success; the speedy exhaustion of two editions has enabled the author to make certain emendations which add greatly to its value. It can confidently be commended to the student as a safe and reliable guide. LEARED (arthur), M.D., F. R.C.P. IMPERFECT DIGESTION: ITS CAUSES AND TREATMENT. The Sixth Edition, Revised and Enlarged. . . . ' . $1.50 KOLLMEYER (a. h.), A. M., M. D. Professor of Materia Medica and Therap: utics, Montreal College. CHEMIA COARTATA ; or, The Key to Modern Chemistry. With Numerous Tables, Tests, &c., &c. Price, .... $2.25 LIVEING (EDWARD), M. D. ON MEGRIM, SICK-HEADACHE, AND SOME ALLIED DISORDERS. With Colored Plate. Octavo . . . $5.25 22 LEWIN (dr. george). Professor at the Fr,-WiIh. University, and Surgeon-in-Chief of the Syphilitic Wards and Skin Diseases of the Charity Hospital, Berlin. THE TREATMENT OF SYPHILIS by Subcutaneous Sublimate Injections. With a Lithographic Plate illustrating the Mode and Proper Place of administering the Injections, and of the Syringe used for the purpose. Translated by Carl Prcegler, M.D., late Surgeon in the Prussian Service, and E. H. Gale, M.D., late Surgeon in the United States Army. Price . . . . . . . . $1.50 MASON (FRANCIS), F. R. C. S., Surgeon and Lecturer on Anatomy at St. Thomas' Hospital, &c. THE SURGERY OF THE FACE. With 100 Illustrations, En- graved on Wood, of Various Operations Performed. Octavo. Cloth. Price, $2.25 LIZARS (john), M. D. Late Professor of Surgery in the Royal College of Surgeons, Edinburgh. THE USE AND ABUSE OF TOBACCO. From the Eighth Edinburgh Edition. i2mo. Price, in flexible cloth, . $0.50 This little work contains a History of the introduction of Tobacco, its general characteris- tics ; practical observations upon its effects on the system; the opinion of celebrated profes- sional men in regard to it, together with cases illustrating its deleterious influence, &c., &c. MACNAMARA (c.). Surgeon to the Ophthalmic Hospital, and Professor of Ophthalmic Medicine in the Medical College, Calcutta. MANUAL OF THE DISEASES OF THE EYE. The Third Edition, carefully Revised; with Additions, and numerous Colored Plates, Diagrams of the Eye, many Illustrations on Wood, Snellen's Test Types, &c., &c. Price ...... $4.00 MARSH (SYLVESTER). SECTION-CUTTING. A Practical Guide to the Preparation and Mounting of Sections for the Microscope - special prominence being given to the subject of Animal Sections. With Illustrations. Cloth. Price, $0.60 MACKENZIE (morell), M. D., Physician to the Hospital for Diseases of the Throat, &c. GROWTHS IN THE LARYNX. Their History, Causes, Symp- toms, &c. With Reports and Analysis of One Hundred Cases. With Colored and other Illustrations. Price ..... $2.00 OTHER WORKS BY THE SAME AUTHOR. THE LARYNGOSCOPE IN THROAT DISEASES. With an Appendix on Rhinoscopy. Third Edition, Enlarged. With New Il- lustrations. Price ........ THE DISEASES OF THE THROAT AND NOSE. Including The Pharynx, The Larynx, Trachea, (Esophagus, Nose, Neck, &c. With numerous Illustrations. Preparing. DIPHTHERIA. Its Nature, Varieties, and Treatment. Price, $075 PHARMACOPCEIA OF THE HOSPITAL FOR DISEASES OF THE THROAT. With One Hundred and Fifty Formulae for Gar- gles, &c., &c. Fourth Edition. Preparing. 23 MEIGS AND PEPPER. A PRACTICAL TREATISE ON THE DISEASES OF CHIL- DREN. By J. Forsyth Meigs, M.D., Fellow of the College of Physi- cians of Philadelphia, &c., &c., and William Pepper, M.D., Physician to the Philadelphia Hospital, &c. Sixth Edition, thoroughly Revised and greatly Enlarged, forming a Royal Octavo Volume of over 1000 pages. Price, bound in cloth, $6.00; leather . . . $7.00 It is the most complete work on the subject in our language. It contains at once the re- sults of personal, and the experience of others. Its quotations frotn the most recent author- ities, at home and abroad, are ample, and we think the authors deserve congratulations for having produced a book unequalled for the use of the student and indispensable as a work of reference for the practitioner. - American Medical Journal. MEARS (j. ewing), M. D., Demonstrator of Surgery in Jefferson Medical College, &c. PRACTICAL SURGERY : Including Surgical Dressings, Bandag- ing, Amputation, &c., &c. 227 Illustrations. For the use of Students. Price, $2.00 MENDENHALL (george), M.D, Professor of Obstetrics in the Medical College of Ohio, &c. MEDICAL STUDENT'S VADE MECUM. A Compendium of Anatomy, Physiology, Chemistry, the Practice of Medicine, Surgery, Obstetrics, Diseases of the Skin, Materia Medica, Pharmacy, Poisons, &c., &c. Eleventh Edition, Revised and Enlarged, with 224 Illustra- tions. In cloth ......... $2.00 MAXSON (EDWIN R.), M.D., Formerly Lecturer on the Practice of Medicine in the Geneva Medical College, &c. THE PRACTICE OF MEDICINE $3.00 MARSHALL (john), F.R.S., Professor of Surgery, University College, London. PHYSIOLOGICAL DIAGRAMS. Life-size, and Beautifully Col- ored. An Entirely New Edition, Revised and Improved, illustrating the whole Human Body, each Map printed on a single sheet of paper, seven feet long and three feet nine inches broad. No. 1. The Skeleton and Ligaments. No. 7. The Brain and Nerves. No. 2. The Muscles, Joints, and Animal Me- No. 8. The Organs of the Senses and Organs chanics. of the Voice. Plate 1. No. 3. The Viscera in Position. - The Struc- No. 9. The Organs of the Senses. Plate 2. ture of the Lungs. No. 10. The Microscopic Structure of the No. 4. The Organs of Circulation. Textures. Plate 1. No. 5. The Lymphatics or Absorbents. No. 11. The Microscopic Structure of the No. 6. The Digestive Organs. Textures. Plate 2. Price of the Set, Eleven Maps, in Sheets, ..... $50.00 " " " " handsomely Mounted on Canvas, with Rollers, and varnished, ..... $80.00 An Explanatory Key to the Diagram. Price . . . . $0.50 MADDEN (t. m.), M.D. Author of " Climatology and the Use of Mineral Waters." THE HEALTH RESORTS OF EUROPE AND AFRICA for the Treatment of Chronic Diseases. A Hand-Book the result of the Author's own Observations during several years of Health-Travel in many Lands, containing, also, the substance of the Author's former Work on Climatology and the Use of Mineral Waters. Octavo. Price $2.50 MAUNDER (c. f.), F.R. C.S. Surgeon to the London Hospital j formerly Demonstrator of Anatomy at Guy's Hospital. OPERATIVE SURGERY. Second Edition, with One Hundred and Sixty-four Engravings on Wood. Price . . . $2.25 BY SAME AUTHOR. SURGERY OF THE ARTERIES, including Aneurisms, Wounds, Haemorrhages, Twenty-seven Cases of Ligatures, Antiseptic, etc. With 18 Illustrations. Price ........ $1.50 MAYNE (r. g.), M. D„ and MAYNE (j.), M. D. MEDICAL VOCABULARY: An Explanation of all Names, Synonyms, Terms, and Phrases used in Medicine and the Relative Branches of Medical Science. 4th Edition. 450 pages. Price, $3.00 MAYS (THOMAS J.), M. D. ON THE THERAPEUTIC FORCES. An Effort to Consider the Action of Medicines in the Light of the Doctrine of Conservation of Force. i2mo. Cloth. Price ...... $1.25 MARTIN (john h.). Author of Microscopic Objects, &c, A MANUAL OF MICROSCOPIC MOUNTING. With Notes on the Collection and Examination of Objects, and upwards of One Hun- dred and Fifty Illustrations. Second Edition, Enlarged. Price, $2.75 MEADOWS (ALFRED), M.D. Physician to the Hospital for Women, and to the General Lying-in Hospital, &c. MANUAL OF MIDWIFERY. A New Text-Book. Including the Signs and Symptoms of Pregnancy, Obstetric Operations, Diseases of the Puerperal State, &c., &c. Second American from the Third Lon- don Edition. Revised and Enlarged. With 145 Illustrations. $3.00 This book is especially valuable to the Student as containing in a condensed form a large amount of valuable information on the subject which it treats. It is also clear and methodi- cal in its arrangement, and therefore useful as a work of reference for the practitioner. The Illustrations are numerous and well executed. MILLER (james), F. R. C. S. Professor of Surgery University of Edinburgh. ALCOHOL, ITS PLACE AND POWER. From the Nineteenth ■ Glasgow Edition. 121110. Cloth flexible. Price . . . $0.50 This work was prepared by Professor Miller at the special request of the Scottish Temper- ance League, who were anxious to have a work of high authority, presenting the medical view of the subject that could be freely disseminated among all classes. ♦ MILLER and LIZARS. ALCOHOL: Its Place and Power. By James Miller, F.R.S.E., late Professor of Surgery in the University of Edinburgh, &c.-THE USE AND ABUSE OF TOBACCO. By John Lizars, late Professor to the Royal College of Surgeons, &c. The Two Essays in One Volume. i2mo. $1.00 24 25 MARSDEN (ALEXANDER), M. D. A NEW AND SUCCESSFUL MODE OF TREATING CERTAIN FORMS OF CANCER. Second Edition, Colored Plates. . $3.00 MACDONALD (j. d.), M. D., Deputy Inspector-General of Hospitals, Assistant Professor of Hygiene, Army Medical School, &c, A GUIDE TO THE MICROSCOPICAL EXAMINATION OF DRINKING WATER. With Twenty Full-page Lithographic Plates, References, Tables, etc., etc. Octavo. Price . . . $2.75 NORRIS (GEORGE w.), M. D., Late Surgeon to the Pennsylvania Hospital, &c. CONTRIBUTIONS TO PRACTICAL SURGERY, including numerous Clinical Histories, Drawn from a Hospital Service of Thirty Years. In one Volume, Octavo. Price . . . . $4.00 OTT (isaac), M. D., Late Demonstrator of Experimental Physiology in the University of Pennsylvania. THE ACTION OF MEDICINES. With Twenty-two Illustrations. Octavo. Cloth. Price ....... $2.00 OGSTON (FRANCIS AND FRANCIS, JR.), M. D. Professor of Medical Jurisprudence, and Assistant Professor in the University of Aberdeen. LECTURES ON MEDICAL JURISPRUDENCE. With Copper- plate Illustrations. Octavo. Cloth ..... $6.00 PHYSICIAN'S VISITING LIST, PUBLISHED ANNUALLY. SIZES AND PRICES. For 25 Patients weekly. Tucks, pockets, and pencil, . . . $1.00 50 " " " " " . . . 1.25 75 " " " " " . . . 1.50 100 " " " " " . . 2.00 _ << 1 f Jan. to June I ,, JO . " 2 VOls. ] juIy | " ... 2.50 100 2 vols' I July to Dec. J • ' • 3-0° INTERLEAVED EDITION. For 25 Patients weekly, interleaved, tucks, pockets, &c., . . 1.25 50 " " " " " . . 1.50 .. ,, , f Jan. to June} ,, JO 2 V01S. | Ju)y tQ " . . 3.00 This Visiting List has now been published Twenty-seven Years, and has met with such uni- form and hearty approval from the Profession, that the demand for it has steadily increased from year to year. POWER, HOLMES, ANSTIE, and BARNES. REPORTS ON THE PROGRESS OF MEDICINE AND SUR- GERY, PHYSIOLOGY, OPHTHALMIC MEDICINE, MID- WIFERY, DISEASES OF WOMEN AND CHILDREN, MATERIA MEDICA, &c. Edited for the Sydenham Society of London. Octavo. Price $2.00 26 PARKES (EDWARD A.), M. D., Professor of Military Hygiene in the Army Medical School, &c, A MANUAL OF PRACTICAL HYGIENE. The Fifth Revised and Enlarged Edition, for Medical Officers of the Army, Civil Medical Officers, Boards of Health, &c., &c. With many Illustrations. One Volume Octavo. Price ....... $6.00 This work, previously unrivalled as a text-book for medical officers of the army, is now equally unrivalled as a text-book for civil medical officers. The first book treats in succes- sive chapters of water, air, ventilation, examination of air, food, quality, choice, and cooking of food, beverages, and condiments; soil, habitations, removal of excreta, warming of houses, exercise, clothing, climate, meteorology, individual hygienic management, disposal of the dead, the prevention of some common diseases, disinfection, and statistics. The second book is devoted to the service of the soldier, but is hardly less instructive to the civil officer of health. It is, in short, a comprehensive and trustworthy text-book of hygiene for the scientific or general reader.- Loudon Lancet. POWER (henry), M. B., F. R .C. S„ Senior Ophthalmic Surgeon to St. Bartholomew's Hospital, THE STUDENT'S GUIDE TO THE DISEASES OF THE EYE. With Engravings. Preparing. PENNSYLVANIA HOSPITAL REPORTS. EDITED BY A COMMITTEE OF THE HOSPITAL STAFF. J. M. Da Costa, M. D., and William Hunt, M. D. Vols. 1 and 2 ; each volume containing upwards of Twenty Original Articles, by former and present Members of the Staff, now eminent in the Profession, with Lithographic and other Illustrations. Price per volume . $2.00 The first Reports were so favorably received, on both sides of the Atlantic, that it is hardly necessary to speak for them the universal welcome of which they are deserving. The papers are all valuable contributions to the literature of medicine, reflecting great credit upon their authors. The work is one of which the Pennsylvania Hospital may well be proud. It will do much towards elevating the profession of this country.- American Journal of Obstetrics. PAGET (JAMES), F.R.S., Surgeon to St. Bartholomew's Hospital, &c. SURGICAL PATHOLOGY. Lectures delivered at the Royal Col- lege of Surgeons of England. Third London Edition, Edited and Revised by William Turner, M. D. With Numerous Illustrations. Price, in cloth, $7.00; in leather ...... $8.00 A new and revised edition of Mr. Paget's Classical Lectures needs no introduction to our readers. Commendation would be as superfluous as criticism out of place. Every page bears evidence that this edition has been " carefully revised."-American Medical Journal. PEREIRA (Jonathan), M. D., F. R. S., &c. PHYSICIAN'S PRESCRIPTION BOOK. Containing Lists of Terms, Phrases, Contractions, and Abbreviations used in Prescriptions, with Explanatory Notes, the Grammatical Constructions of Prescrip- tions, Rules for the Pronunciation of Pharmaceutical Terms, a Proso- diacal Vocabulary of the Names of Drugs, &c., and a Series of Abbre- viated Prescriptions illustrating the use of the preceding terms, &c. ; to which is added a Key, containing the Prescriptions in an unabbreviated Form, with a Literal Translation, intended for the use of Medical and Pharmaceutical Students. From the Fifteenth London Edition. Price, in cloth, * 1.00; in leather, with Tucks and Pocket, . . $1.25 27 PARSONS (charles), M. D., Honorary Surgeon to the Dover Convalescent Homes, &c., &c. SEA-AIR AND SEA-BATHING. Their Influence on Health a Practical Guide for the Use of Visitors at the Seaside. i8mo. $0.60 PARKER (langston), F. R. C. S. L. THE MODERN TREATMENT OF SYPHILITIC DISEASES. Containing the Treatment of Constitutional and Confirmed Syphilis, with numerous Cases, Formulse,&c.,&c. Fifth Edition,Enlarged. $4.25 PRINCE (david), M.D. PLASTIC AND ORTHOPEDIC SURGERY. Containing 1. A Report on the Condition of, and Advances made in, Plastic and Ortho- pedic Surgery up to the Year 1871. 2. A New Classification and Brief Exposition of Plastic Surgery. With numerous Illustrations. 3. Ortho- pedics: A Systematic Work upon the Prevention and Cure of Deformities. With numerous Illustrations. Octavo. Price . . . $4.50 This is a good book upon an important practical subject; carefully written and abun- dantly illustrated. It goes over the whole ground of deformities-from cleft-palate and club-foot to spinal curvatures and ununited fractures. It appears, moreover, to be an original book. - Medical and Surgical Reporter. SAME AUTHOR. GALVANO-THERAPEUTICS. A Revised reprint of A Report made to the Illinois State Medical Society. With Illustrations. Price, $1-25 PIESSE (g. w. Septimus), Analytical Chemist. WHOLE ART OF PERFUMERY. And the Methods of Obtaining the Odors of Plants; the Manufacture of Perfumes for the Handkerchief, Scented Powders, Odorous Vinegars, Dentifrices, Pomatums, Cosmet- ics, Perfumed Soaps, &c. ; the Preparation of Artificial Fruit Essences, &c. Second American from the Third London Edition. With Illus- trations. PIGGOTT (a. snowden), M. D., Practical Chemist. COPPER MINING AND COPPER ORE. Containing a full Descrip- tion of some of the Principal Copper Mines of the United States, the Art of Mining, the Mode of Preparing the Ore for Market, &c., &c. $1.00 PAVY (f.w.),M. D., F. R.S. DIABETES. Researches on its Nature and Treatment. Third Re- vised Edition. Octavo PHYSICIAN'S PRESCRIPTION BLANKS, with a Margin for Duplicates, Notes, Cases, &c., &c. Price, per package, Price, per dozen . 28 RINDFLEISCH (dr. edward). Professor of Pathological Anatomy, University of Bonn. TEXT-BOOK OF PATHOLOGICAL HISTOLOGY. Ai: Intro duction to the Study of Pathological Anatomy. Translated from the German, by Wm. C. Kloman, M.D., assisted by F. T. Miles, M.D., Professor of Anatomy, University of Maryland, &c., &c. Containing Two Hundred and Eight elaborately executed Microscopical Illustra- tions. Octavo. Price, bound in Cloth, . . . $5.00 " " Leather, . . . .6.00 This is now confessedly the leading book, and the only complete one on the subject in the English language. The London Lancet says of it: " Rindneisch's work forms a mine which no pathological writer or student can afford to neglect, who desires to interpret aright pathological structural changes, and his book is consequently well known to readers of Ger- man medical literature. What makes it especially valuable is the fact that it was originated, as its author himself tells us, more at the microscope than at the writing-table. Altogether the book is the result of honest hard labor. It is admirably as well as profusely illustrated, furnished with a capital Index, and got up in a way that is worthy of what must continue to be the standard book of the kind." ROBERTS (FREDERICK T.)., M. D., B. Sc. Assistant Physician and Teacher of Clinical Medicine in the University College Hospital) Assistant Physician Brompton Consumption Hospital, &c. A HAND-BOOK OF THE THEORY AND PRACTICE OF MEDICINE. . Second Edition, Revised and Enlarged. Cloth, $5.00 Leather, 6.00 This work has been prepared mainly for the use of Students, and its object is to present in as condensed a form as the present extent of Medical Literature will permit, and in one volume, such information with regard to the Principles and Practice of Medicine, as shall be sufficient not only to enable them to prepare for the various examinations which they may have to undergo, but also to guide them in acquiring that Clinical Knowledge which can alone properly fit them for assuming the active duties of their profession. The work is also adapted to the wants of very many members of the profession who are already busily engaged in general Practice, and consequently have but little leisure and few opportunities for the perusal of the larger works on Practice or of the various special monographs. REYNOLDS (j. russell), M. D., F. R. S., Lecturer on the Principles and Practice of Medicine, University College, London. LECTURES ON THE CLINICAL USES OF ELECTRICITY. Delivered at University College Hospital. Second Edition, Revised and Enlarged. Price$1.00 RYAN (michael), M. D. Member of the Royal College of Physicians, PHILOSOPHY OF MARRIAGE, in its Social, Moral, and Physi- cal Relations; with an Account of the Diseases of the Genito-Urinary Organs, &c. Price . . . . . . . . $1.00 This is a philosophical discussion of the whole subject of Marriage, its influences and results in all their varied aspects, together with a medical history of the reproductive func- tions of the vegetable and animal kingdoms, and of the abuses and disorders resulting from it in the latter. It is intended both for the professional and general reader. 29 RADCLIFFE (charles bland), M.D., Fellow of the Royal College of Physicians of London, &c. LECTURES ON EPILEPSY, PAIN, PARALYSIS, and other Disorders of the Nervous System. With Illustrations. . . $1.50 The reputation which Dr. Radcliffe possesses as a very able authority on nervous affections will commend his work to every medical practitioner. We recommend it as a work that will throw much light upon the Physiology and Pathology of the Nervous System. - Canada Medical Journal. ROBERTSON (a.), M.D., D.D.S. A MANUAL ON EXTRACTING TEETH. Founded on the Anatomy of the Parts involved in the Operation, the kinds and proper construction of the instruments to be used, the accidents likely to occur from the operation, and the proper remedies to retrieve such accidents. A New Revised Edition. The author is well known as a contributor to the literature of the profession, and as a clear, terse, and practical writer. The subject is one to which he has devoted considerable attention, and is treated with his usual care and ability. The work is valuable not only to the dental student and practitioner, but also to the medical student and surgeon. - Dental Cosmos. REESE (john j.), M. D., Professor of Medical Jurisprudence and Toxicology in the University of Pennsylvania. AN ANALYSIS OF PHYSIOLOGY. Being a Condensed View of the most important Facts and Doctrines, designed especially for the Use of Students. Second Edition, Enlarged. . . . $1.50 SAME AUTHOR. THE AMERICAN MEDICAL FORMULARY. Price . $1.50 A SYLLABUS OF MEDICAL CHEMISTRY. Price . $1.00 RICHARDSON (joseph), D.D S. Late Professor of Mechanical Dentistry, &c., die. A PRACTICAL TREATISE ON MECHANICAL DENTISTRY. Second Edition, much Enlarged. With over 150 beautifully executed Illustrations. Octavo. Price, in cloth, $4.00 ; in leather, . £4.50 This work does infinite credit to its author. Its comprehensive style has in no way in- terfered with most elaborate details where this is necessary; and the numerous and beautifully executed wood-cuts with which it is illustrated make the volume as attractive as its instruc- tions are easily understood. -Edinburgh Med. Journal. ROBERTS (lloyd d.), M.D., Vice-President of the Obstetrical Society of London, Physician to St. Mary's Hospital, Manchester. THE STUDENT'S GUIDE TO THE PRACTICE OF MID- WIFERY. With 95 Illustrations. Price .... $2.00 RUTHERFORD (william), M. D., F. R. S. E. Professor of the Institutes of Medicine in the University of Edinburgh. OUTLINES OF PRACTICAL HISTOLOGY FOR STUDENTS AND OTHERS. Second Edition, Revised and Enlarged. With Illus- trations, &c. Price . . . . . . . . $2.00 30 RIGBY and MEADOWS. DR. RIGBY'S OBSTETRIC MEMORANDA. Fourth Edition, Revised and Enlarged, by Alfred Meadows, M. D., Author of "A Manual of Midwifery," &c. Price ..... $0.50 ROYLE'S MANUAL OF MATERIA MEDICA AND THERA- PEUTICS. The Sixth Revised and Enlarged Edition. Containing all the New Preparations according to the New British, American, French, and German Pharmacopoeias, the New Chemical Nomencla- ture, etc., etc. Edited by John Harley, M. D., F. R. C. P., Assistant Physician and Lecturer on Physiology at St. Thomas's Hospital. With 139 Illustrations, many of them new. One vol., Demy Octavo. $5.00 STOCKEN (james), L D. S. R. C. S., lecturer on Dental Materia M dica and Therapeutics and Dental Surgeon to National Dental Hospital. THE ELEMENTS OF DENTAL MATERIA MEDICA AND THERAPEUTICS. With Pharmacopoeia. Second Edition. $2.25 SANDERSON, KLEIN, FOSTER, and BRUNTON. A HAND-BOOK EOR THE PHYSIOLOGICAL LABORATORY. Being Practical Exercises for Students in Physiology and Histology, by E. Klein, M. D., Assistant Professor in the Pathological Laboratory of the Brown Institution, London; J. Burdon-Sanderson, M. D., F. R. S., Professor of Practical Theology in University College, Lon- don; Michael Foster, M.D., F.R.S., Fellow of and Praelector of Phys- iology in Trinity College, Cambridge; and T. Lauder Brunton, M.D., D.Sc., Lecturer on Materia Medica in the Medical College of St. Bar- tholomew's Hospital. Edited by J. Burdon-Sanderson. The Illus- trations consist of One Hundred and Twenty-three octavo pages, including over Three Hundred and Fifty Figures, with appropriate letter-press explanations attached and references to the text. Price, in one volume, Cloth, $6.00; in Leather, $7.00; or in two volumes, Cloth, $7.00. Vol. L, containing the Text, sold separately, $4.00. We feel that we cannot recommend this work too highly. To those engaged in physiologi- cal work as students or teachers, it is almost indispensable: and to those who are not, a perusal of it will by no means be unprofitable. The execution of the plates leaves nothing to be desired. They are mostly original, and their arrangement in a separate volume has great and obvious advantages. -Dublin Journal of Medical Sciences. SIEVEKING (e. h.), M.D., F.R.C.S. THE MEDICAL ADVISER IN LIFE ASSURANCE. Price $2.00 This book supplies, in a concise and available form, such facts and figures as are required by the Physician or Examiner to assist him in arriving at a correct estimate of the many contingencies upon which life insurance rests. SWAIN (william paul), F.R.C.S., Surgeon to the Royal Albert Hospital, Devonport. SURGICAL EMERGENCIES: A MANUAL CONTAINING CONCISE DESCRIPTIONS OF VARIOUS ACCIDENTS AND EMERGENCIES, WITH DIRECTIONS FOR THEIR IMME- DIATE TREA TMENT. With numerous Wood Engravings. In one volume, i?mo. Cloth. Price ...... $2.00 31 STILLE (ALFRED), M. D. Professor of the Theory and Practice of Medicine in the University of Pennsylvania, &lc. EPIDEMIC MENINGITIS ; or, Cerebro-Spinal Meningitis. In one volume, Octavo. . . . . . . . . $2.00 This monograph is a timely publication, comprehensive in its scope, and presenting within a small compass a fair digest of our existing knowledge of the disease, particularly accept- able at the present time. It is just such a one as is needed, and may be taken as a model for similar works.- American Journal Medical Sciences. SMITH (william Robert), Resident Surgeon, Hants County Hospital. LECTURES ON THE EFFICIENT TRAINING OF NURSES FOR HOSPITAL AND PRIVATE WORK. With Illustrations. 121110. Cloth. Price ........ $2.00 SMITH (heywood), M. D., Physician to the Hospital for Women, &c. PRACTICAL GYNAECOLOGY. A Hand-Book for Students and Practitioners. With Illustrations. Price . . . . $1.50 " It is obviously the work of a thoroughly intelligent practitioner, well versed in his art." -British Medical Journal. SANSOM (ARTHUR ERNEST), M.B., Physician to King's College Hospital, &c. CHLOROFORM. Its Action and Administration. Price $1 50 BY SAME AUTHOR. LECTURES ON THE PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART, intended for Students and Practitioners. $1.50 SCANZONI (f. w. von), Professor in the University of Wurzburg. A PRACTICAL TREATISE ON THE DISEASES OF THE SEXUAL ORGANS OF WOMEN. Translated from the French. By A. K. Gardner, M.D. With Illustrations. Octavo. . $5.00 STOKES (william), Regius Professor of Physic in the University of Dublin. THE DISEASES OF THE HEART AND THE AORTA. Octavo. .......... $3-oo SYDENHAM SOCIETY'S PUBLICATIONS. New Series, 1859 to 1878 inclusive, 20 years, 81 vols. Subscriptions received, and back years furnished at $9.00 per year. Full prospectus, with the Reports of the Society and a list of the Books published, furnished free upon application. SANKEY (w. h. o.), M. D., F. R. C. P. LECTURES ON MENTAL DISEASES. Octavo . . $3.00 32 SWERINGEN (hiram v.). Member American Pharmaceutical Association, &c. PHARMACEUTICAL LEXICON. A Dictionary of Pharmaceu- tical Science. Containing a concise explanation of the various subjects and terms, of Pharmacy, with appropriate selections from the collateral sciences. Formulae for officinal, empirical, and dietetic preparations; selections from the prescriptions of the most eminent physicians of Europe and America; an alphabetical list of diseases and their defini- tions; an account of the various modes in use for the preservation of dead bodies for interment or dissection; tables of signs and abbrevia- tions, weights and measures, doses, antidotes to poisons, &c., &c. Designed as a guide for the Pharmaceutist, Druggist, Physician, &c. Royal Octavo. Price in cloth . . . . . . $3.00 " leather . . . . . .4.00 SEWILL (h. e.), M. R. C. S., Eng., L. D. S., Dental Surgeon to the West London Hospital. THE STUDENT'S GUIDE TO DENTAL ANATOMY AND SURGERY. With 77 Illustrations. Price . . . . $1.50 SHEPPARD (EDGAR), M. D. Professor of Psychological Medicine in King's College, London. MADNESS, IN ITS MEDICAL, SOCIAL, AND LEGAL AS- PECTS. A series of Lectures delivered at King's College, London. Octavo. Price . . . . . . . . . $2.25 . SAVAGE (henry), M. D., F. R. C. S. Consulting Physician to the Samaritan Free Hospital, London. THE SURGERY, SURGICAL PATHOLOGY, and Surgical Anat- omy of the Female Pelvic Organs, in a Series of Colored Plates taken from Nature: with Commentaries, Notes, and Cases. Third Edition, greatly enlarged. A quarto volume. Price . $12.00 SAVORY and MOORE. A CONDENSED COMPENDIUM OF DOMESTIC MEDICINE AND COMPANION TO THE MEDICINE CHEST. With En- gravings. 121110. Cloth. Price ...... $0.50 SUTTON (FRANCIS), F. C. S. A SYSTEMATIC HAND-BOOK OF VOLUMETRIC ANALYSIS, or the Quantitative Estimation of Chemical Substances by Measure, Applied to Liquids, Solids, and Gases. Third Edition, enlarged. With numerous Illustrations. Now Ready. Price . . $5.00 SMITH (EUSTACE), M.D. Physician to the East London Hospital for Diseases of Children, &c. CLINICAL STUDIES OF DISEASES OF THE LUNGS IN CHILDREN. Price $2.50 33 TANNER (thomas hawkes), M.D., F.R. C.P., &c. THE PRACTICE OF MEDICINE. Sixth American from the last London Edition. Revised, much Enlarged, and thoroughly brought up to the present time. With a complete Section on the Diseases Peculiar to Women, an extensive Appendix of Formulae for Medicines, Baths, &c., &c. Royal Octavo, over noo pages. Price, in cloth, $6.00; leather . . . . . . . . . . $7.00 There is a common character about the writings of Dr. Tanner - a characteristic which constitutes one of their chief values : they are all essentially and thoroughly practical. Dr. Tanner never, for one moment, allows this utilitarian end to escape his mental view. He aims at teaching how to recognize and how to cure disease, and in this he is thoroughly suc- cessful. ... It is, indeed, a wonderful mine of knowledge.-Medical Times. SAME AUTHOR. A PRACTICAL TREATISE ON THE DISEASES OF IN- FANCY AND CHILDHOOD. Third American from the last Lon- don Edition, Revised and Enlarged. By Alfred Meadows, M.D., London, M.R.C.P., Physician to the Hospital for Women and to the General Lying-in Hospital, &c., &c. Price .... $3mo TANNER'S INDEX OF DISEASES AND THEIR TREAT- MENT. Second Edition. Carefully Revised. With many Additions and Improvements. By W. H. Broadbent, M. D., F. R. C. P., Phy- sician to the London Fever Hospital, &c., &c. Octavo. Cloth. S3.00 A MEMORANDA OF POISONS. A New and much Enlarged Edition. Price ......... $0.75 TYSON (james), M.D., Lecturer on Microscopy in the University of Pennsylvania, &.c. THE CELL DOCTRINE. Its History and Present State, with a Copious Bibliography of the Subject, for the use of Students of Medi- cine and Dentistry. With Colored Plate, and numerous Illustrations on Wood. Second Edition. Price ..... $2.00 BY SAME AUTHOR. A PRACTICAL GUIDE TO THE EXAMINATION OF URINE. For the use of Physicians and Students. With a Colored Plate and numerous Illustrations Engraved on Wood. Second Edition. Just Ready. Price . . . . . . . . . $1.25 TAFT (Jonathan), D. D. S., Professor of Operative Dentistry in the Ohio College, &c. A PRACTICAL TREATISE ON OPERATIVE DENTISTRY. Third Edition, thoroughly Revised, with Additions, and fully brought up to the Present State of the Science. Containing over 100 Illustra- tions. Octavo. Price, in cloth, $4.25. In leather, . . $5-00 TURNBULL (laurence), M. D. THE ADVANTAGES AND ACCIDENTS OF ARTIFICIAL ANAESTHESIA. A Manual of Anaesthetic Agents, Modes of Admin- istration, etc. 25 Illustrations. 121110. Cloth . . . $1.00 THOMPSON (e. s.), M.D., Physician to Hospital for Consumption, etc. COUGHS AND COLDS. Their Causes, Nature, and Treatment. i2mo. Cloth. Price ....... $0.60 34 TROUSSEAU (a.), Professor of Clinical Medicine to the Faculty of Medicine, Paris, &c. LECTURES ON CLINICAL MEDICINE. Delivered at the Hotel Dieu, Paris. Translated from the Third Revised and Enlarged Edition by P. Victor Bazire, M.D., London and Paris; and John Rose Cor- mack, M.D., Edinburgh, F.R.S., &c. With a full Index, Table of Con- tents, &c. Complete in Two volumes, royal octavo, bound in cloth. Price $8.00 ; in Leather ....... $10.00 Trousseau's Lectures have attained a reputation both in England and this country far greater than any work of a similar character heretofore written ; and, notwithstanding but few medical men could alford to purchase the expensive edition issued by the Sydenham Society, it has had an extensive sale. In order, however, to bring the work within the reach of all the profession, the publishers now issue this edition, containing all the lectures as contained in the five-volume edition, at one-half the price. The London Lancet, in speaking of the work, says: It treats of diseases of daily occurrence and of the most vital interest to the practitioner. And we should think any medical library absurdly incomplete now which did not have alongside of Watson, Graves, and Tanner, the ' Clinical Medicine' of Trousseau." The Sydenham Society's Edition of Trousseau can also be furnished in sets, or in separate volumes, as follows: Volumes I., II., and III., $5.00 each. Volumes IV. and V., $4.00 each. TILT (edward John), M.D. THE CHANGE OF LIFE IN HEALTH AND DISEASE. A Practical Treatise on the Nervous and other Affections incidental to Women at the Decline of Life. Third London Edition. Price, $3.00 SAME AUTHOR. A HAND-BOOK OF UTERINE THERAPEUTICS AND OF DISEASES OF WOMEN. Fourth London Edition. Price, $3.50 TOYNBEE (j.), F.R.S. ON DISEASES OF THE EAR. Their Nature, Diagnosis, and Treatment. A new London Edition, with a Supplement. By James Hinton, Aural Surgeon to Guy's Hospital, &c. And numerous Illus- trations. Octavo. . . . . • . . $5.00 THOMPSON (sir henry), F.R.C.S., &c. ON THE PREVENTIVE TREATMENT OF CALCULOUS DISEASE, and the Use of Solvent Remedies. Second Edition. $1.00 PRACTICAL LITHOTOMY AND LITHOTRITY. Second Edi- tion, with Illustrations. ........ $3.50 THORNTON (w. pugin), M.D. Surgeon to Hospital for Diseases of the Throat, &c. ON TRACHEOTOMY, Especially in Relation to Diseases of the Larynx and Trachea. With Photographic and other Illustrations. Price $1.75 THOROWGOOD (john c.), M.D., Lecturer on Materia Medicaatthe Middlesex Hospital. THE STUDENT'S GUIDE TO MATERIA MEDICA. With Engravings on Wood. $2.00 TYLER SMITH (w.), M.D., Physician, Accoucheur, and Lecturer on Midwifery, &c. ON OBSTETRICS. A Course of Lectures. Edited by A. K. Gardner, M.D. With Illustrations., Octavo. ' . . . $5.00 35 THOROWGOOD (j. c.), M. D„ Physician to the City of London Hospital for Diseases of the Chest, and to the West London Hospital, &c. NOTES ON ASTHMA. Its various Forms, their Nature and Treatment, including Hay Asthma, with an Appendix of Formulae, &c. Third Edition. Price . . . . . . . $1.50 TIDY (c. meymott), M. D., Professor of Chemistry In London Hospital. A HAND-BOOK OF MODERN CHEMISTRY, Organic and In- organic. 8vo. 600 pages. Cloth, red edges. Price . . $5.00 TOMES (john), F.R.S. Late Dental Surgeon to the Middlesex and Dental Hospitals, &c. A SYSTEM OF DENTAL SURGERY. The Second Revised and Enlarged Edition, by Charles S. Tomes, M.A., Lecturer on Dental Anatomy and Physiology, and Assistant Dental Surgeon to the Dental Hospital of London. With 263 Illustrations. Trice . .' $5.00 TOMES (c.s.),M. A. Lecturer on Anatomy and Physiology, and Assistant Surgeon to the Dental Hospital of London. A MANUAL OF DENTAL ANATOMY, HUMAN AND COM- PARATIVE. With 179 Illustrations. Now Ready. Price . $3-5° TRANSACTIONS OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA. New Series. VOLUMES I., IL, & III. Price, per volume . . . . $2.50 THUDICHUM (john l. w.), M. D., Lettsomian Professor of Medicine, Medical Society, London, &c. ON PATHOLOGY OF THE URINE. Including a Complete Guide to Analysis. A new Revised and Enlarged Edition. With Illustrations. Octavo. Price . . . . . • $5-00 TOLAND (h. h.), M. D., ' Professor of the Principles and Practice of Surgery in the University of California. LECTURES ON PRACTICAL SURGERY. Second Edition. With Additions and numerous Illustrations. Price, in cloth, $4.50 " in leather, 5.00 TIBBITS (herbert), M. D. Medical Superintendent of the National Hospital for the Paralyzed and Epileptic, &c. A HANDBOOK OF MEDICAL ELECTRICITY. With Sixty- Tour large Illustrations. Small octavo. Price . . . $1-50 The author of this volume is the translator of Duchenne's great work on " Localized' Elec- trization." Avoiding contested points in electro-physiology and therapeutics, he has pre- pared this handbook as containing all that is essential for the busy practitioner to know, not only when, but in explicit and FULL detail, how to use Electricity in the treatment of disease, and to make the practitioner as much at home in the use of his electrical as his other medical instruments. 36 VIRCHOW (rudolphe), Professor, University of Berlin. CELLULAR PATHOLOGY. 144 Illustrations. Octavo. $5.00 BY SAME AUTHOR. POST-MORTEM EXAMINATIONS. A Description and Expla- nation of the Method of Performing Them in the Dead House of the Berlin Charite Hospital. Price ..... $0.75 ARTHUR VAC HER, Translator and Editor of Fresenius's Chemical Analysis. A PRIMER OF CHEMISTRY. Including Analysis. i8mo. Cloth. Price ......... $0.50 WARING (edward john), F.R. C. S., F.L.S., &c., &c. PRACTICAL THERAPEUTICS. Considered chiefly with refer- ence to Articles of the Materia Medica. Third American from the last London Edition. Price, in cloth, $4.00; leather . . $5.00 There are many features in Dr. Waring's Therapeutics which render it especially valuable to the Practitioner and Student of Medicine, much important and reliable information being found in it not contained in similar works; also in its completeness, the convenience of its ar- rangement, and the greater prominence given to the medicinal application of the various articles of the Materia Medica in the treatment of morbid conditions of the Human Body, &c. It is divided into two parts, the alphabetical arrangement being adopted throughout. It contains also an excellent Index of Diseases, with a list of the medicines applicable as remedies, and a full Index of the medicines and preparations noticed in the work. WYTHE (joseph h), A.M., M.D., &c. THE PHYSICIAN'S POCKET, DOSE, AND SYMPTOM BOOK. Containing the Doses and Uses of all the PrincipalArticles of the Materia Medica, and Original Preparations; A Table of Weights and Measures, Rules to Proportion the Doses of Medicines, Common Abbreviations used in Writing Prescriptions, Table of Poisons and Antidotes, Classifi- cation of the Materia Medica; Dietetic Preparations, Table of Symptom- atology, Outlines of General Pathology and Therapeutics, &c. The Eleventh Revised Edition. Price, in cloth, $1.00; in leather, tucks, with pockets, ......... $1.25 BY SAME AUTHOR. THE MICROSCOPIST, a Compendium of Microscopic Science, Micro-Mineralogy, Micro-Chemistry, Biology, Histology, and Patho- logical Histology. Elegantly Illustrated. Price . . . $4.50 WILKS AND MOXON. LECTURES ON PATHOLOGICAL ANATOMY. By Samuel Wilks, M.D., F.R.S., Physician to, and Lecturer on Medicine at, Guy's Hospital. Second Edition, Enlarged and Revised. By Walter Moxon, M.D., F.R.S., Physician to, and late Lecturer on Pathology at, Guy's Hospital. . . . . . . . . . . $6.00 WILSON (ERASMUS), F.R.S. HEALTHY SKIN. A Popular Treatise on the Skin and Hair, their Preservation and Management. Eighth Edition. Cloth. . $1.00 37 WILSON (GEORGE), M. A., M. D. Medical Officer to the Convict Prison at Portsmouth. A HANDBOOK OF HYGIENE AND SANITARY SCIENCE. With Engravings. Third Edition, carefully Revised. Containing Chapters on Public Health, Food, Air, Ventilation and Warming, Water, Water Analysis, Dwellings, Hospitals, Removal, Purification, Utilization of Sewage and Effects on Public Health, Drainage, Epi- demics, Duties of Medical Officers of Health, &c., &c. Price $3.00 WAGSTAFFE (william Warwick), F. R. C. S. Assistant-Surgeon and Lecturer on Anatomy at St. Thomas's Hospital. THE STUDENT'S GUIDE TO HUMAN OSTEOLOGY. With Twenty-three Lithographic Plates and Sixty Wood Engravings. i2mo. Cloth. Price .......... $3.00 WARD ON AFFECTIONS OF THE LIVER AND INTESTI- NAL CANAL; with Remarks on Ague, Scurvy, Purpura, &c. $2.00 WHEELER (c. gilbert), M. D., Professor of Chenrstry in the University of Ch'cago. MEDICAL CHEMISTRY : Including the Outlines of Organic and Physiological Chemistry. Based in Part upon Riche's Manual De Chimie. Octavo. Cloth. Price ...... $3.00 WILSON (erasmus), F. R. C. S., &c. CONTAINING THREE HUNDRED AND SEVENTY-ONE ILLUSTRATIONS. THE ANATOMIST'S VADE MECUM. A Complete System of Human Anatomy. The Ninth Revised and Enlarged London Edition. Edited and fully brought to the Science of the day by Prof. George Buchanan, Lecturer on Anatomy in Anderson's University, Glasgow, with many New Illustrations, prepared expressly for this Edition. Price . $5-oo WEDL (carl), M. D. Professor of Histology, &c., in the University of Vienna. DENTAL PATHOLOGY. The Pathology of the Teeth. With Special Reference- to their Anatomy and Physiology. First American Edition, translated by W. E. Boardman, M.D., with Notes by Thos. B. Hitchcock, M.D., Professor of Dental Pathology and Therapeutics in the Dental School of Harvard University, Cambridge. With 105 Illustrations. . . . Price, in Cloth, $3.50; Leather, $4.50 This work exhibits laborious research and medical culture of no ordinary character. It covers the entire field of Anatomy, Phvsiology, and Pathology of the Teeth. The author, Prof. Wedl, has thoroughly mastered the subject, using with great benefit to the book the very valuable material left by the late Dr. Heider, Professor of Dental Pathology in the Uni versity of Vienna, the result of the life-long work of this eminent man. WILKES M. D. Physician to, and Lecturerat, Guy's Hospital. LECTURES ON DISEASES OF THE NERVOUS SYSTEM. Delivered at Guy's Hospital. With Additions. Numerous Illustrative Cases, etc. . . . . . . . . . $5.00 38 WOODMAN and TIDY. A TEXT-BOOK OF FORENSIC MEDICINE AND TOXI- COLOGY. By W. Bathurst Woodman, M. D., St. And., Assistant Physician and Lecturer on Physiology at the London Hospital ; and C. Meymott Tidy, M. A., M. B., Lecturer on Chemistry, and Professor of Medical Jurisprudence and Public Health, at the London Hospital. With Numerous Illustrations. Now ready, cloth, $7.50; leather, $8.50 WELLS (j. scelberg), Ophthalmic Surgeon to King's College Hospital, &c. TREATISE ON THE DISEASES OF THE EYE. Illustrated by Ophthalmoscopic Plates and numerous Engravings on Wood. The Third London Edition. Cloth, $5.00; leather . . . $6.00 This is the author's own edition, printed in London under his supervision, and issued in this country by special arrangement with him. SAME AUTHOR. ON LONG, SHORT, AND WEAK SIGHT, and their Treatment by the Scientific Use of Spectacles. Fourth Edition Revised, with Additions and numerous Illustrations. Price . . . $2.25 WRIGHT ( HENRY G. ), M. D., Member of the Royal College of Physicians, &.c. ON HEADACHES. Their Causes and their Cure. From the Lon- don Edition. Seventh Thousand ...... $0.50 WILSON (Joseph), M. D., Medical Director, U. S. N. NAVAL HYGIENE - Human Health and the Means of Prevent- ing Disease. With Illustrative Incidents derived from Naval Experi- ence. Second Edition. With Colored Lithographs and other Illus- trations. Octavo. Price ....... $3.00 WALTON (HAYNES), Surgeon in Charge of the Ophthalmic Department of, and Lecturer on Ophthalmic Medicine and Surgery in, St, Mary's Hospital. A PRACTICAL TREATISE ON DISEASES OF THE EYE, Third Edition. Rewritten and enlarged. With five plain, and three colored full-page plate's, numerous Illustrations on Wood, Test Types, &c., &c. Octavo volume of nearly 1200 pages. Price . $9-00 WATERS (a. t. h.), M.D., F.R.C.P., &c. DISEASES OB'THE CHEST. Contributions to their Clinical His- tory, Pathology, and Treatment. Second Edition, Revised and Enlarged. With numerous Illustrative Cases and Chapters on Haemoptysis, Hay Fever, Thoracic Aneurism, and the Use of Chloral in certain Diseases of the Chest, and Plates. Octavo. Price .... $4.00 WALKER (ALEXANDER), Author of " Woman," " Beauty," &c, INTERMARRIAGE; or, the Mode in which, and the Causes why, Beauty, Health, Intellect result from certain Unions, and Deformity, Disease, and Insanity from others. With Illustrations. 121110. $1.00 Medical Text-Books and Works of Reference, PUBLISHED BY LINDSAY & BLAKISTON, PHILADELPHIA. For Sale by all Booksellers or mailed FHEE on receipt of price. Roberts's Hand-Book of the Practice of Medicine. Uniformly commended by the Pro- fession and the Press. Octavo Price, bound in cloth, $5.00 ; leather, $6.00. Trousseau's Clinical Medicine. Complete in two volumes, octavo. Price, in cloth, $8.00; leather, $10.00. Aitken's Science and Practice of Medicine. Third American, from the Sixth London Edition. Two volumes, royal octavo. Price, in cloth, $12.00 ; leather, $1-4.00. Sanderson's Hand-Book for the Physiological Laboratory. Exercises for Students in Physiology and Histology. 353 Illustrations. Price, in one volume, cloth, $6.00; leather, $7.00. Cazeaux's Text-Book of Obstetrics. From the Seventh French Edition, Revised and greatly Enlarged. With Illustrations. Cloth, :g6.co; leather, $7.00. Waring's Practical Therapeutics. From the Third London Edition. Cloth, $4.00; leather, $5.00. Rindfleisch's Pathological Histology. Containing 208 elaborately executed Microscopical Illustrations. Cloth, $5.00 ; leather, $6.oj. Meigs and Pepper's Practical Treatise on the Diseases of Children. Sixth Edition. Cloth, $6.00 ; leather, $7.00. Tanner's Practice of Medicine. The Sixth American Edition, Revised and Enlarged. Cloth, $6.00; leather, $7.00. Tanner and Meadow's Diseases of Infancy and Childhood. Third Edition. Cloth, $3.00. Biddle's Materia Mediea for Students. The Eighth Revised and Enlarged Edition. With Illustrations. Price, $4.00. Harris's Principles a/id Practice of Dentistry. The Tenth Revised and Enlarged Edition. Cloth, $6.50; leather, $7.50. Soelberg Wells on Diseases of the Eye. The Third London Edition. Illustrated by Ophthalmoscopic Plates and other Engravings. Cloth, $5.00 ; leather, $6.00. Woodman and Tidy's Forensic Medicine and l exicology. Illustrated. 8vo. Cloth, $7.50; sheep, $8.50. Byford on the Uterus. A New, Enlarged, and thoroughly Revised Edition. Numerous Illustra- tions. Price, $2.50. t Hewitt's Diagnosis and Treatment of the Diseases of Women. Third Edition doth, .54.00; leather, $5.00. Headland on the Action of Medicines. Sixth American Edition. Price, $3.00. Atthill's Diseases of Women. Fifth Edition. Numerous Illustrations. Price, $2.25. Mea low s Manual of Midwifery. Illustrated. 'third Enlarged Edition, including the Signs and Symptoms of Pregnancy, etc. Price, $3.00. Bloxom's Chemistry. Inorganic and Organic. Third Edition. 276 Illustrations. Cloth, $4.00; leather, $5.00. Walton's Practical Treatise on Diseases of the Eye. The Third Revised and Enlarged Edition. Numerous Illustrations, Test Types, etc. Price, $9.00. Jones and Sieveking's Pathological Anatomy. A New Enlarged Edition, edited bv T. F. Payne, M. D. With Illustrations. Price, $5.50. Wilks and Moxon's Pathological Anatomy. Second Edition, Enlarged and Revised. Price, $6.00. Carpenter's Microscope and its Revelations. The Fifth Edition, very much Enlarged. With 500 Illustrations. Price, $5.00. Wilson's Anatomist's Vade Mecum. The Ninth Enlarged London Edition. Price, $5.00. Parke's Manual of Practical Hygiene. The Fifth Enlarged Edition. Price, $6.00. Richardson's Mechanical Dentistry. Second Edition, much Enlarged. With over 150 Illustrations. Price, in cloth, $4.00; leather, $4.50. Beale's Use of the Microscope in Practical Medicine. Fourth Edition. 500 Illustra- tions. Price, $7.50 Sweringen's Dictionary of Pharmaceutical Science. Octavo. Price, $3,00. Mackenzie's Growths in the Larynx. With Numerous Colored Illustrations. Price, $2.00. Tanner's Index of Diseases, and their Treatment. A New Edition. Price, $3.00. Tidy's Hand-Book of Modern Chemistry. Organic and Inorganic. Price, $5.00. Charteris' Hand-Book of Practice. Illustrated. Price,$2.00. Popular Medical, Scientific, and Hygienic Books. MANY OF THEM NEW OR NEW EDITIONS REDUCED IN PRICE. Bennett on Nutrition. In Health and Disease. Second Edition, Revised and Enlarged. Price . $2.50 Madden's Health Resorts of Europe and Africa, including Climatol- ogy, the Use of Mineral Waters, etc. New Edition Acton's Functions and Disorders of the Reproductive Organs in Childhood, Youth, Adult Age, and Advanced Life. The Fifth Edition Revised, with Additions •. 2.50 Wilson's Hand-Book of Hygiene and Sanitary Science. The Third Revised and Enlarged Edition, with Illustrations 3.00 Wilson on the Skin and Hair. Their Preservation and Management. Eighth Revised Edition 1.00 Well's on Long, Short, and Weak Sight. Their Treatment by the Use of Spectacles. A New Revised Edition 2.50 Bloxam's Laboratory Teaching; or, Progressive Exercises in Practical Chemistry. Third Edition. 89 Engravings 2.00 Smith on the Training of Nurses for Hospital and Private Work. Illus- trated,.... 2.25 Frankland's How to Teach Chemistry. Edited by G. Geo. Chaloner. Illustrated 1.25 Kollmeyer's Key to Modern Chemistry,with numerous Tables,Tests, etc. 2.25 Parson's Sea-Bathing and Sea-Air. Their Influence on Health. A Guide for Visitors at the Seaside. Cloth 60 Wright on Headaches. Their Causes and their Cure. Fourth Edit. Cloth. 50 Cottle, The Hair. In Health and Disease. I2mo 75 Chavasse on the Training of Children. Their Mental Culture, etc 1.00 Hufeland on the Art of Prolonging Life. Edited by Erasmus Wilson, M. D. I2mo. Cloth 1.00 Ryan, The Philosophy of Marriage in its Social, Moral, and Physical Relations 1.00 Walker on Intermarriage. The Causes why Beauty, Health, Intellect, etc., Result from Certain Unions, etc. With Illustrations 1.00 Lizars on Tobacco, Its Use and Abuse. Eighth Edition. I2mo. Cloth. 50 Miller on Alcohol. Its Place and Power. From the Nineteenth Edition.... 50 Miller and Lizars on Alcohol and Tobacco. Two Essays in One Vol. 1.00 Birch, Constipated Bowels. The Causes and Means of Cure 1.00 Overman on Mineralogy, Assaying, and Mining 1.00 Piggot on Copper Mining and Copper Ore 1.00 Savory and Moore's Condensed Compendium of Domestic Medi- cine and Companion to the Medicine Chest 50 Bernay's Notes for Students in Chemistry. Sixth Edition 1.25 Vacher, A Primer of Chemistry, including Analysis. Cloth 50 Day on Headaches. Their Nature, Causes, and Cure 2.00 Prosser James on Sore Throat: Its Nature, Varieties, and Treatment.... 2.00 Copies of the above sent by mail, post-paid, upon receipt of annexed price. LINDSAY & BLAKISTON, Publishers, 25 South Sixth Street, Philadelphia.